Medicare Part D

Whether you should sign up for a Medicare Part D plan depends on your circumstances. You may have creditable drug coverage from employer or retiree insurance. If so, you don’t need to enroll in a PDP until you lose this coverage. Also, some people already enrolled in certain low-income assistance programs may be automatically enrolled in a Medicare drug plan and receive additional financial assistance paying for their medicines.

 

Each Part D plan has a list of covered drugs, called its formulary. If your drug is not on the formulary, you may have to request an exception, pay out of pocket, or file an appeal.

A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D plans must include at least two drugs from most categories and must cover all drugs Avail Medicare’s prescription drug benefit (Part D) is the part of Medicare that provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare).

If you want to get Part D coverage, you have to choose and enroll in a private Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with drug coverage (MAPD). Enrollment is optional (though recommended to avoid incurring future penalties) and only allowed during approved enrollment periods. Typically, you should sign up for Part D when you first become eligible to enroll in Medicare.

Each Part D plan has a list of covered drugs, called its formulary. If your a drug is not on the formulary, you may have to request an exception, pay out of pocket, or file an appeal.

A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:

  • HIV/AIDS treatments
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • Immunosuppressant drugs
  • Anticancer drugs (unless covered by Part B)

Part D plans must also cover most vaccines, except for vaccines covered by Part B.

Some drugs are explicitly excluded from Medicare coverage by law, including drugs used to treat weight loss or gain, and over-the-counter drugs.

Note: For certain drugs or under specific circumstances, your drugs may be covered by Part A or Part B.

 

How to help with high drug costs

 

If you are enrolled in Part D and having trouble affording your prescriptions or finding plans that will cover your drugs, there are several ways you may be able to fill the gaps in your coverage:

  1. Apply for Extra Help. This federal program helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage.
  2. Check for State Pharmaceutical Assistance Programs (SPAPs) in your state. These programs help residents pay for prescription drugs. Each program works differently, and not all states have SPAPs.
  3. Keep your retiree drug coverage. Talk to you or your spouse’s former employer to find out if your retiree drug coverage will fill gaps in Medicare’s prescription drug benefit.
  4. Buy an enhanced Part D plan. Enhanced plans charge higher monthly premiums than basic plans but typically offer a wider range of benefits. For instance, these plans may not have a deductible, may provide extra coverage during the donut hole, and may have a broader formulary. Some of these plans may also cover excluded drugs. Keep in mind that benefits vary by plan.
  5. Join a Medicare Advantage Plan that offers drug coverage with lower out-of-pocket costs. Medicare HMOs, PPOs, and other private health plans may offer drug coverage that lowers your up-front costs (such as the deductible). However, you will need to look at more than just the plan’s drug coverage: Also make sure the plan covers your preferred doctors and hospitals at a cost you can afford.

Keep in mind that after reaching catastrophic coverage, costs for your covered drugs will drop significantly.

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