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What Is Medicare Part D?

Part D prescription drug benefits are administered through private insurance plans approved by the federal government.

November 13, 2017 - By Erica Block - read

Medicare Part D is a private, government-regulated prescription drug plan that works with your Medicare coverage. More than 41 million seniors and disabled adults living in the United States.

Understanding Medicare Part D

There are two ways to get Medicare Part D coverage:

  1. If you are enrolled in Medicare Part A and Medicare Part B (Original Medicare), you can get Part D coverage by enrolling in a stand-alone prescription drug plan (PDP).
  2. If you’re enrolled in a Medicare Advantage (Part C) plan, you can get Part D coverage by enrolling in a Medicare Advantage plan that includes drug benefits. These plans are known as Medicare Advantage Prescription Drug Plans (MA-PDs).

Part D prescription drug coverage is optional. Although Medicare beneficiaries aren’t required to enroll in Medicare Part D, there can be consequences–such as permanent late fees or delayed coverage–if they don’t sign up for Part D coverage when they are first eligible.

Medicare Part D prescription drug coverage is provided and coordinated by Medicare-approved private insurance companies. There isn’t one single Medicare Part D plan. Rather, a number of different insurance providers sell Part D plans. Most Medicare beneficiaries will have several Part D plan options to choose from.

Each Part D Drug Plan maintains a formulary. Like traditional health insurance plans, Medicare Part D policies have a formulary, or a list of drugs covered under the plan. Each Part D plan establishes its own formulary, so the particular drugs which are covered tend to vary from plan to plan.

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Who Is Eligible for Medicare Part D Coverage?

  • Anyone who is eligible for Original Medicare (Part A and Part B) is entitled to Medicare prescription drug coverage (known as Part D) – regardless of their income.
  • No physical exams are required to enroll in Medicare Part D and people cannot be denied coverage due to health reasons, or because they have pre-existing conditions or take multiple medications.

What Does Medicare Part D Cover?

Formulary: Part D drug coverage varies from plan to plan. Each Part D prescription drug plan has its own list of covered drugs (known as a ‘formulary’).

Tiered Pricing: Most Medicare Part D plans categorize the prescription drugs they cover into different cost “tiers.” A drug in a lower tier will generally cost less and have a lower copay than a drug in a higher tier.

Prior Authorization: If you take a medication not included in your plan formulary, your doctor may be able to request a formulary exception – or “prior authorization” –  on your behalf if the medication you take is deemed “medically necessary.”

What Is NOT Covered by Medicare Part D?

Because each Medicare Part D plan provider establishes its own drug formulary, this list is by no means exhaustive. That said, Part D plans typically do not cover:

  • Weight-loss drugs;
  • Drugs for hair growth;
  • Fertility drugs;
  • Drugs for erectile dysfunction;
  • Over-the-counter drugs and vitamins; or
  • Drugs already covered under Medicare Parts A and B (i.e. drugs given during inpatient hospital stays or visits to the doctor)

How Much Does Medicare Part D Cost?

The cost of Medicare Part D coverage is hard to estimate because Part D premium, deductible, and coinsurance costs will vary from plan to plan.

The total cost of your Part D drug coverage will depend on these variables:

  • The particular Medicare Part D plan you choose;
  • The specific drugs you take, and whether those medications are included in your plan’s formulary;
  • Whether or not you fill your prescriptions at a pharmacy in your plan’s network; and
  • Whether you qualify for financial assistance to help you pay for Medicare Part D.

The total cost of Medicare Part D coverage includes the following expenses:

  • Premium: There is no standard premium amount for Part D plans. Each Part D drug plan sets their own monthly premium prices. Note: some Medicare Advantage plans do not charge an extra premium for prescription drug coverage.
  • Annual Deductible: Nearly all Medicare Part D plans require policyholders to meet an annual deductible (no more than $400 in 2017) before their drug coverage kicks in. Deductible amounts vary; however, the federal government sets a maximum amount that Part D deductibles cannot exceed. Deductible maximums are established on an annual basis and can change from year to year.
  • Copayments or Coinsurance: You’ll pay either a flat copayment (eg. $10) or a certain percentage of a drug’s total cost (eg. 20 percent) for each prescription you fill during your plan’s initial coverage period. Most Part D plans have three or four different price levels (“tiers”) for drug copays.
  • Coverage Gap: Once your total drug spending costs (what your plan has paid, plus your deductible and copay expenditures) exceed a certain amount ($3,700 in 2017), you have reached the so-called “Medicare coverage gap,” also referred to as the Medicare “donut hole.” If you spend enough on prescription drugs to enter the coverage gap, your coinsurance costs for brand-name drugs will increase to 40 percent of the drug’s total price; for generics your coinsurance costs will increase to 51 percent of the drug’s total price.

What Is the Medicare Coverage Gap?

Most Part D prescription drug plans are subject to a coverage gap known as the Medicare “donut hole.” While you’re in the so-called “coverage gap”, you’ll pay higher copays for your prescription drugs for a period of time.

Medicare beneficiaries who receive financial assistance (in the form of a subsidy or through a state pharmaceutical assistance program) to help pay for Part D are usually exempt from the Medicare Part D “donut hole.” Instead of entering the coverage gap, those receiving financial assistance are charged a nominal copay for each medication they fill once their drug spending exceeds the coverage gap threshold amount.

2017 Medicare Coverage Gap: The Donut Hole

Medicare Coverage Gap | Medicare Donut Hole | What is Medicare Part D? HealthCare.comHow Does Part D Relate to Other Medicare Programs?

  • Part D and Original Medicare (Medicare Part A and/or Part B): If you have Original Medicare (Part A and Part B), Medicare Part D isn’t automatically included as part of your Medicare benefits package. You obtain Part D coverage by enrolling in a stand-alone Medicare Part D prescription drug plan that works alongside your Original Medicare benefits.
  • Part D and Medicare Advantage (Medicare Part C): Many Medicare Advantage plans (MA-PDs) include prescription drug coverage in their plan benefits. These plans are usually provided through a health maintenance organization (HMO) or a preferred provider organization (PPO).
  • Part D and Medigap: Although Medigap policies no longer include prescription drug coverage, those who have drug coverage through their current Medigap policy are entitled to keep this benefit. However, once you enroll in a Part D prescription drug plan, your Medigap insurance policy must remove your Medigap prescription drug coverage and adjust your premiums accordingly.

Enrollment Periods: When Can I Sign Up for Medicare Part D?

Part D prescription drug coverage is optional, so you will need to “opt into” this coverage. If you’re signing up for Part D for the first time, you may do so during one of the following three enrollment periods:

  1. Initial Enrollment Period (IEP): If you are signing up for Medicare for the first time, you may sign up for a Part D drug plan at any point during your initial, seven-month enrollment window. Your initial enrollment period begins three months before your 65th birthday and ends three months after your 65th birthday (or, if you’re younger and have disabilities, the month you receive your 25th Social Security disability payment). You can also use your IEP to enroll in a Part D prescription drug plan if you turned 65 while living abroad or in prison.
  2. Special Enrollment Period (SEP): You may sign up for a Part D plan during an SEP in certain circumstances — for example, if you lose your current drug coverage (such as from an employer or union), or if you turned 65 before moving abroad or going to prison and now require prescription drug coverage upon your return or release. You can also enroll in a Part D plan during a special enrollment period if you already have Part D coverage and subsequently moved your main residence to a location outside your plan’s geographic service area. You do not have to request an SEP in these circumstances; just go ahead and sign up for a Part D drug plan.
  3. Annual Open Enrollment Period (OEP): If you miss the deadline to enroll in Part D during an IEP or an SEP, then you must wait until the next Annual Open Enrollment Period to enroll in a Part D prescription drug plan. Medicare’s annual Open Enrollment Period runs every year from October 15 to December 7, with your newly-elected drug coverage taking effect on January 1. The OEP also serves as an annual opportunity for Medicare beneficiaries already enrolled in Part D to switch from one plan to another.

Final Steps: How Do I Enroll in Medicare Part D?

How can I enroll in Medicare Part D?

Once you’ve considered your plan options and have identified which Part D plan you want, there are several ways to enroll.

  1. Over the Phone: Call Medicare at +1 (800) 633-4227. If you’re hard of hearing and use TTY, you can call 877-486-2048 toll free.
  2. Sign up online at Medicare.govIf you use the website’s plan finder tool to compare your coverage options, you can enroll in your chosen Medicare Advantage plan by clicking on the “Enroll” button alongside that plan’s name. You will be required to fill out an application form.
  3. Sign up by directly contacting a Part D provider: You can enroll by reaching out directly to an insurer offering Part D plans. You can enroll over the phone, or by visiting the provider’s website.

Taking the Next Steps

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