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Medicare Part D Explanation

Part D of Medicare covers prescription drugs only. In order to have coverage, you must elect a stand-alone plan, along with Original Medicare or enroll into a Medicare Advantage plan that also includes prescription drug coverage (MA-PD).

Part D is offered by private insurers only (like United Health Care or Blue Cross and Blue Shield) that contract with Medicare to offer Part D. There is no “Government Option” Part D benefit like there are with A and B. Each Part D plan is offered by a private insurance company.

There are a few moving “parts” to Part D. They are:

  • Monthly premium – in Missouri, monthly Part D premiums range from $17 – $149.20 for 2017. In Virginia & Maryland, the monthly premiums range from $15 – $45.
  • Deductible amount – the amount you have to pay before your coverage kicks in.
  • Copay – the amount you pay at a pharmacy after you meet your deductible and will vary from plan to plan and from drug to drug. Drug copays range from $2 for a generic up to $100 for a brand name.
  • Coverage Gap – AKA the “Donut Hole”. Watch video explaining the Donut Hole here. Learn about the Future of the Donut Hole here.
  • Formulary – each company has a different list of drugs they cover. This is crucial as the drugs you currently take may or may not be covered by different plans.
  • Preferred Pharmacy – while this isn’t as big of an issue, it is still something to consider. Most pharmacies will take any Part D plan from any company but should still be confirmed.

Choosing a Part D Plan

Since each company charges a different monthly premium, covers different drugs and has different copays, what is the best way to choose a plan? We think that Medicare.gov’s Prescription Plan Finder is the best place to start. This unbiased source allows you to plug in your zip code and current prescriptions to find which plan will be your TOTAL LOWEST COST (taking into consideration ALL factors, not just price.)

While this is a great place to start, we suggest giving us a call before signing up as there are a few other things to be aware of.

Part D Coverage Rules

Each Part D company has 3 different coverage rules that can cause headaches (note: the headaches caused may cause additional prescription drug usage!) when getting certain prescriptions covered:

PA – Prior Authorization

All Plans may require a “prior authorization” to make sure certain prescription drugs are used correctly and that only when medically necessary. This means before your plan will cover a certain drug, your doctor must first contact your plan and show there’s a medically-necessary reason why you must use that particular prescription drug.

ST – Step Therapy

Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, your plan may require you to first try a generic prescription drug (if available), then a less expensive brand-name prescription drug on its formulary, before it will cover a similar, more expensive brand-name prescription drug. However, if you’ve already tried the similar, less expensive drugs and they didn’t work, or if your doctor believes your medical condition makes it medically necessary for you to be on the more expensive step-therapy prescription drug, he or she can contact your plan to ask for an exception. If your doctor’s request is approved, your plan will cover the step-therapy prescription drug.

QL – Quantity Limits

For safety and cost reasons, plans may limit the number of prescription drugs they cover over a certain period of time. For example, most people who are prescribed a heartburn medication take 1 capsule per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication. If you need more, you may need your doctor’s help to provide more information to the plan.

When evaluating your Part D options, you should consider the restrictions of your medicine along with the different factors mentioned above. The lowest priced plan may not cover your prescriptions or require you to change your drugs. This ultimately can lead to higher prices in the long run along with the added stress and frustration of having to visit your doctor to get your prescriptions switched over.

Part D Enrollment

Medicare Part D companies renew their contracts with Medicare annually. This means that each year, the moving “parts” can move. You then have the opportunity to adjust your coverage accordingly. This can be done during the “Annual Enrollment Period” or AEP from 10/15 to 12/7 of each year. Your change begins 1/1 of the following year.

We can help! Having advised clients on Part D since its inception, we are able to use all available resources to help pick the plan that fits your prescriptions and situation. Give us a call at 636-205-4205 for a free, no obligation phone consultation to help narrow down your choices.

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