Part D of Medicare is essentially insurance for your medication requirements. Anyone who is eligible to benefit from Medicare Part A and Part B, is qualified to enroll for drug coverage with Medicare Part D regardless of their income. Enrolling in Medicare Part D is voluntary, except for seniors who qualify for Medicare and Medicaid and are automatically enrolled in a prescription drug plan even though they might not have selected the plan themselves.

However, if you currently use Medicare to pay for your prescriptions, you may face penalties since you must get them with a Medicare drug plan as soon as you are eligible for Medicare. If you are a beneficiary, you can sign up for an Independent Part D Medicare Plan in combination with the Original Medicare benefits.

Costs of Medicare Part D +

When enrolled in an individual Part D plan, your monthly premiums will be payable to the insurer allowing you to benefit from your insurer’s pharmacy network by paying a co-pay or a percentage of the medication costs. The cost of your plan will be dependent on the annual inflation rate and Social Security.

As a Part D member, you may be faced with increases in the cost of out-of-pocket medications before qualifying for catastrophic coverage after you reach your spending limit. You may also have to pay higher costs out-of-pocket during the deduction and initial coverage phases. It is important to keep these in mind when you sign up for a Medicare Part D plan.

Medicare contributes 80% of the total cost of drugs and your plan will cover 15%. After that, you will be required to pay 5% or higher for the overall cost.

Stages of the Part D Plan +

There are four main stages of Part D plan: Annual Deductible, Initial Coverage, The Coverage Gap and Catastrophic Coverage.

Annual Deductible: Like any benefit plan, you will have a set deductible for prescription drugs. You will be required to pay the network discount price until you reach your deductible. Schemes may lower the Part D deductible or cancel altogether if this occurs.

Initial Coverage: During the initial coverage stage, you will be required to pay a co-pay for your prescriptions. This list of drugs on the formulary in your plan will be split into different levels with a specific co-pay for each.

The Coverage Gap: After you have reached your coverage limit for the year, you will enter the coverage gap. During this gap, you will have discounts on generic medications and be required to pay 25% of the brand name medication. This gap will continue until you have out-of-pocket spending that has reached the cap amount set for the current calendar year.

Catastrophic Coverage: Once you reach the end of your coverage gap, your plan will cover 95% of your drug formulary costs for the rest of the year. This helps you cap potential expenses you may incur if you have any expensive medications.

Medicare Part D Spending +

Every year, Medicare keeps track of your TrOOP (True Out-of-Pocket Costs). This can help prevent you from paying some costs twice. For example, if you reach your deductible in one plan and switch into a different Part D scheme later in the year, your coverage gap and catastrophic costs will still work the same.

Your plan will also change each year on January 1 and may have different changes in the amounts.

What Can Affect My Part D Coverage? +

Medicare encourages drug carriers to put some safety rules in place to protect your coverage and contain costs.

Quantity limits: These are restrictions put in place to cap the amount of medication you can purchase. Should a situation occur where you need your primary doctor to prescribe more than the quantity limit, they will need to inform your insurance provider to complete an exception form.

Prior authorization: Before a pharmacy can start working on your prescription, your doctor will need to seek approval from your plan. This may require your doctor to send proof of a prescription, especially if the medication is very strong or expensive.

Step therapy: Sometimes your plan will demand you try out cheaper alternative medications to help treat your condition before they cover the costs of your prescribed medication. If the alternative medication turns out to be more effective, then both of you save money. If the alternative medication is not helpful, your doctor can help file a drug exception request for coverage using this as proof the medication was not working.

Restrictions of Medicare Part D +

Unfortunately, nearly all Medicare Part D plans have some limitations, especially when it comes to narcotics, opiates and pain medication. If you need a significant amount of pain medication, please keep in mind this will require more paperwork regardless of your plan.

Some medications may even be outside of Part D coverage, such as compound medication. If this is the case, please contact our insurance agent in Las Vegas, Nevada, at 702-242-3200 for assistance on what steps to take.

If you have any additional questions, please reach out to us at SBI Benefits.