Medicare Part D Prescription Drug Coverage
How do I get Medicare Part D coverage?
You can get Medicare Part D coverage through:
- Stand-alone Part D plans run by companies that contract with Medicare. To enroll in Part D, you must have Medicare Part A and/or Part B.
- Medicare Advantage Plans. Most of these plans offer prescription drug coverage. To join a Medicare Advantage Plan, you must have Part A and Part B. Be aware that some Medicare Advantage plans do not offer prescription drug coverage. Patients enrolled in such plans may not join stand-alone prescription drug plans; if you do, it will disenroll you from your Medicare Advantage plan.
You must also live in the service area of the Medicare Part D plan you want to join.
For more help, call HICAP at 1-800-434-0222.
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What if I already have prescription drug coverage through my employer?
It is of critical importance that you understand your employer's prescription drug coverage. Before deferring enrollment in Part D, you need to verify your employer offers creditable prescription drug coverage (coverage Medicare considers at least as comprehensive as Part D) or you could be faced with penalties down the road. In some cases, enrolling in a Part D plan will actually disenroll you from your employer's drug coverage. It could even eliminate other health coverage benefits for you and your dependents without the ability to re-enroll. If you have questions about your employer group health coverage, contact your company's human resources department or benefits administrator so you can make informed decisions for you and your family.
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What is creditable prescription drug coverage?
Creditable prescription drug coverage is coverage Medicare considers at least as comprehensive as Medicare Part D. Companies or organizations that offer creditable coverage must provide annual notice each October to their Part D-eligible members about whether their coverage is creditable.
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How much does Medicare Part D cost?
Your prescription drug plan costs will depend on which plan you join. There may be a deductible. There will be a monthly premium and co-payments. The amount of co-payment will depend on the total annual cost of the drugs purchased and is divided into three thresholds:
- Initial coverage. Patient pays 25 percent of the cost of the drugs after any applicable deductibles are met.
- Coverage gap (donut hole). Patient receives a 50 percent discount on brand-name drugs and a 7 percent discount on generics.
- After reaching the current out-of-pocket threshhold, patient pays 5 percent and plans pay 95 percent of the cost of the drugs.
The threshold amounts and their exact dollar figures change each year.
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How do I know which Part D plan is right for me?
The best plan is the one that covers your prescriptions for the least cost with the least restrictions. If you are computer literate, you can go to the Medicare website (www.medicare.gov) and use their tools to compare drug plans. You will need to input the names of your prescription medications along with their strength and dosage. After you have entered all of your drugs, the program will provide a complete listing of all the drug plans available to you, from the cheapest to the most expensive. It is a good idea to compare at least three plans and get as much information about each plan as you can before you decide. Pay special attention to whether the plans have restrictions on your specific medications such as prior authorizations (plan may opt not to cover the drug), quantity limits (plan will only cover limited dosage-- additional doses you must pay out-of-pocket), and step therapy (plan may require verification that you have tried less expensive medication to treat your symptoms before covering your preferred drug). See more information about restrictions below.
You can also get help choosing a drug plan by contacting HICAP at 1-800-434-0222 to schedule a one-on-one appointment.
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How do I know a Part D plan includes my medications?
Each Part D plan has a formulary, which is a list of the medications they cover. Formularies are usually "tiered," which means that there will be some "plan-preferred" drugs that will cost less than "non-preferred" drugs. Generic drugs are usually the most cost-effective.
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What about restrictions on a Part D plan's coverage?
Part D plans may have restrictions on your medications such as:
- Prior authorization — Your doctor may need to contact the plan to prove a particular drug is medically necessary before the plan will cover certain prescriptions. Be aware that if the plan denies authorization, you may have to decide between purchasing the drug out-of-pocket or switching to a drug that is covered.
- Quantity limits — Limits how much of a particular medication you may receive in a month. If your dosage exceeds the limit, you will have to pay in full for the excess. You can call the plan to get exact information on quantity limits for the drugs you are taking.
- Step therapy — You must provide verification that you've tried one or more similar, lower cost drugs before the plan will cover the drug your doctor prescribed.
If your doctor believes that one of these coverage rules should be waived, you can ask for an exception. Contact HICAP at 1-800-434-0222 for more information. You may also consult the section of this website on Appeals.
NEXT: Part D Plan Enrollment »
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