Medicare Questions About Part D

What can I do if my medication is not covered?

If a drug you’re prescribed is not on your Part D plan’s formulary (list of covered drugs), you can ask that your Part D plan cover it by requesting a coverage decision. If your plan responds and does not cover the drug your doctor prescribed, you can then file an appeal for the plan to reconsider its decision.

Can Medicare share my personal health information with a friend or loved one who can help me with my Part D plan?

Yes, but Medicare must be alerted to this request in writing. You’ll need to complete the Medicare Authorization to Disclose Personal Health Information form. The form verifies that your personal health information can be shared and you select the person that can speak with Medicare on your behalf.

What is Prior Authorization?

For certain prescription drugs or treatments, special rules may restrict how and when the plan covers them. A prior authorization (PA), sometimes referred to as prior approval or precertification, is a type of restriction where a Medicare plan requests that your doctor get approval from the plan first before the plan will agree to cover the prescribed medication or treatment . Check your plan’s formulary or summary of benefits to see if you need a PA. If you are not sure call your plan for more information.

Call your Part D plan representative to learn more about its prior authorization policy.

Can I switch plans mid-year?

Mid-year changes may be acceptable if you qualify for a Special Enrollment Period (SEP). You may be eligible to switch under certain circumstances, such as if you moved to a new service area or if your existing plan no longer offers Part D coverage. Read more here. The Annual Enrollment Period runs from October 15 through December 7.

What is a Special Enrollment Period (SEP)?

A Special Enrollment Period (or SEP) allows you to make changes to your coverage outside standard enrollment periods if you meet certain special circumstances. Examples of situations that may qualify you for an SEP include your losing creditable coverage, moving to a new service area or if you’re existing plan no longer offers Part D coverage.

Who is eligible for Medicare Part D?

Key Dates for Medicare Annual Enrollment Period


Plan information available:

October 1

Enrollment begins:

October 15

Enrollment ends:

December 7

Note: The late enrollment penalty is 1% of the national average premium for every month you were without Part D prescription drug coverage or other creditable prescription drug coverage following your initial enrollment period, or if you had a break in creditable prescription drug coverage of 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare’s standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Part D coverage.

Medicare Part D prescription drug plans (PDP) provide prescription drug coverage to any U.S. citizen permanently residing in the plan’s service area who is 65 and older, entitled to Medicare Part A and/or enrolled in Medicare Part B.  Additionally, people younger than 65 who qualify for Medicare due to certain disabilities are also eligible for Medicare Part D. You can learn about available Medicare Part D plans starting October 1. The Annual Enrollment Period begins on October 15, and ends on December 7.

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How do I know if my pharmacy is in-network?

There may be two types of pharmacies in a Part D pharmacy network. A standard pharmacy refers to a pharmacy in your plan’s network where you can fill a prescription. A preferred pharmacy is one that works with your plan to reduce your copayment or coinsurance even more than at a standard pharmacy.

Which vaccines are covered under Medicare Part D?

Part D plans must cover all commercially available vaccines (except those covered by Part B). If there is a new preventive vaccine, it may not appear in the formulary, but the plan may still cover the vaccine. You should contact your plan’s customer service to find out about the specific vaccine.

Vaccines covered by Part B:

  • Hepatitis B (If you’re at high or medium risk of contracting the disease)
  • Influenza
  • Pneumonia
What is “step-therapy”?

Step therapy is a requirement that a plan may place on certain covered drugs to help control costs. You must first try certain less-expensive drugs that have been proven safe and effective for your condition before you can move up a “step” to a more expensive medication.

If your earnings exceed a certain amount, you will pay an additional premium called Part D – IRMAA. IRMAA premiums start when an individual hits $85,000 in income, or when a couple filing a joint return has an income of more than $170,000. The Part D – IRMAA premium ranges from $12.70-$72.90. Read more here.

Will I lose my VA coverage if I have Medicare Part D?

No, you can have prescription drug coverage from both Medicare and Veterans Affairs. You can get covered drugs under either program, but the two will never combine to pay for the same prescription. For more information, call VA Benefits at 1-800-827-1000.

How do I sign up for Medicare Part D coverage?

After researching your options and selecting the plan you would like, you can enroll directly by calling the plan’s toll-free phone number or visiting its website. Some plans offer Medicare advisors who can walk you through the enrollment process over the phone. You can also enroll through an insurance agent or broker.

When you enroll, be sure to have the following information handy:

  • Your red, white and blue Medicare ID card
  • Name and information for your emergency contact
  • Information pertaining to other prescription coverage you may have (private insurance, VA benefits, TRICARE, Federal Employee health benefits, state assistance)
  • Your premium payment method. Some plans allow you to pay by check, electronic fund transfer from a checking account, or a credit card if you choose not to have your premium deducted from your Social Security check or Railroad Retirement Board benefit (as applicable).

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Why is there such a difference in premium costs among plans?

Coinsurance vs. Copayment:

After meeting your deductible (if any), you may need to pay coinsurance or a copayment as your share of the cost of a covered prescription drug. Coinsurance is a percentage of the cost of a medication. A copayment is typically a fixed amount.

A Medicare Part D prescription drug plan’s premium is the set cost a person pays each month. The premium is based on a number of factors that may include the size of the plan’s formulary (list of covered drugs), restrictions on how those drugs are covered, as well as extra features of the plan, such as lower copayments or $0/low-cost deductibles. Plans with low premiums might come with higher out-of-pocket costs — including higher deductibles, a smaller list of covered drugs, as well as restrictions on how those drugs are covered. Low-premium plans are also more likely to require members to pay coinsurance — a percentage of the cost of a medication — so out-of-pocket costs can vary widely depending on the medications you take. When determining the overall cost of a plan, along with the premium, you need to also consider deductibles and copayments/coinsurance.  Learn more about Medicare Part D plan premiums.

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Do I need to join the same Medicare Part D plan as my spouse?

No, you do not need to join the same Medicare Part D prescription drug plan (PDP) as your spouse. Medicare covers individuals — it does not jointly cover husband and wife like some employer-provided plans.

There is no financial advantage for spouses to enroll in the same plan. You and your spouse may have very different health conditions and medication needs that could require specific types of coverage. While you may be able to help each other in the selection process, always consider your individual needs when choosing a plan.

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If I’m healthy and not currently taking prescription drugs, should I wait to enroll in a Medicare Part D plan?

Initial Enrollment Period:

The 7-month enrollment window for individuals just turning 65. You can enroll up to 3 months prior to your birth month, the month of your birth, and up to 3 months following your birth month.

Special Enrollment Period:

The enrollment window for those who are already eligible for Medicare, but have a special circumstance, such as moving to another state or losing employer coverage.

Annual Enrollment Period:

The set time each year when most Medicare-eligible beneficiaries who need prescription coverage for the next year must enroll in a plan.

Key Dates for Medicare Annual Enrollment Period


Plan information available:

October 1

Enrollment begins:

October 15

Enrollment ends:

December 7

Note: The late enrollment penalty is 1% of the national average premium for every month you were without Part D prescription drug coverage or other creditable prescription drug coverage following your initial enrollment period, or if you had a break in creditable prescription drug coverage of 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare’s standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Part D coverage.

Being healthy today doesn’t mean that you won’t have medication needs tomorrow. It’s always a good idea to have prescription drug coverage in case your health situation changes.

If you already qualify for Medicare and don’t enroll during the Initial Enrollment Period or Annual Enrollment Period, you will risk not having prescription drug coverage if and when you need it down the road. Also consider that if you enroll late, or don’t enroll when you are first eligible, you may be subject to a permanent premium penalty. Learn more about the late enrollment penalty.

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Are there penalties for not joining a Medicare Part D plan?

You become eligible to enroll in a Medicare Part D prescription drug plan (PDP) when you turn 65 and are eligible for Part A and/or Part B.

If you do not join a Medicare Part D plan when you are first eligible, you may face a late-enrollment penalty. You will have to pay this late-enrollment penalty for as long as you have Part D coverage. Learn more about the late enrollment penalty.

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Can I sign up for coverage under the Affordable Care Act (“Obamacare”)?

The Affordable Care Act, among other things, provides a way for people under age 65 to purchase health and prescription coverage through a Public Health Insurance Exchange. People who are age 65 and over are not eligible to purchase a plan on a Public Health Insurance Exchange. If you are age 65 or older, and you are eligible for Medicare Part A and/or Part B, you should consider enrolling in a Medicare Part D plan.

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What is the Part D Coverage Gap (“donut hole”)? What does it cost?

Centers for Medicare & Medicaid Services (CMS):

The Federal agency that oversees Medicare and Medicaid.

In a standard Medicare Part D plan, the Coverage Gap, also known as the “donut hole,” is the stage of coverage where you pay a higher percentage of the cost of prescription drugs. In 2015, you enter the Coverage Gap once your Part D total drug costs (your deductible plus your copayments and what the plan spends in the initial coverage stage) exceed $2,960. You will pay 45% of the cost of covered brand-name drugs and 65% of the cost of covered generic drugs. If your out-of-pocket costs reach $4,700 in this stage, you will move into the last stage of coverage, the Catastrophic Coverage stage. In this last stage, the plan pays most of the cost of your drugs for the remainder of the calendar year. Not everyone enters the coverage gap because their drug costs won’t be high enough. Some plans offer additional gap coverage beyond the standard benefit however they may charge a higher premium. As part of the Affordable Care Act, the Coverage Gap stage is being phased out and will be eliminated completely by 2020.

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How much does a Medicare Part D plan cost?

Several components of a Medicare Part D prescription drug plan (PDP) impact what your total cost will be:

  • Monthly premium: The plan’s monthly fee. It is a fixed amount, and premiums may vary by plan and the Part D region in which you live.
  • Deductible: The amount you are required to spend out of pocket on your medication before your plan’s coverage begins.
  • Initial Coverage: In this stage of your Part D plan, your medications are covered and you pay a share of the cost as a copayment or coinsurance.
  • Coverage Gap: The third stage of a standard Part D plan begins after you and your plan together have spent a certain amount for covered drugs. Once you enter this stage you will pay a higher share for your covered drugs until you reach a certain amount. Your deductible, coinsurance and copayments all count towards getting you out of the Gap.
  • Catastrophic Coverage: Once you get out of the Gap, you automatically get “catastrophic coverage.” In this last stage of a Part D plan you pay a small copayment or coinsurance for covered medications for the rest of the calendar year.

You should consider all aspects of a plan before enrolling. Sometimes a low monthly premium is associated with high deductibles, high copayments (fixed out-of-pocket costs), or coinsurance (a percentage of the cost of a medication). However, plans with higher premiums may offer added benefits like $0 deductibles, preferred pharmacy networks, lower copayments, and/or discounts for using a home delivery pharmacy.

The size of a plan’s drug formulary (the list of covered drugs) contributes to a plan’s cost. A plan with a smaller, limited formulary is likely to have a lower premium. However, that also means that you could end up paying a great deal of money if you need a medication that is not on their drug list.

Lastly, the level of customer service provided is also reflected in a plan’s cost. Plans that offer specialized Medicare advisors may cost more, but those plans provide you with access to a higher level of specialized service.

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What is a formulary?

A formulary is a list of the medications covered by a plan. Formularies vary in size based on the plan you select. Lower-priced plans may offer fewer prescription drugs on its formulary. You may find that plans that have a higher premium may have a broader formulary, with a wider selection of brand-name and generic medications. You can find out which specific medications are covered by looking at a plan’s drug list during the Open Enrollment period. You can usually review enrollment materials like the formulary online, call Customer Service, or request a formulary be mailed to you.

I am 65, retired and just learned that my employer is no longer providing prescription drug benefits for its retirees. What should I do?

Don’t panic. While losing coverage can be discouraging and stressful, there are many affordable options available under Medicare that may provide you with coverage that better suits your needs and saves you money.

This article offers important information about the many choices available under Medicare, and what steps you need to take to research and select a plan.

What are the benefits of enrolling in Original Medicare and adding a Part D plan vs. enrolling in a Medicare Advantage Plan?

With Medicare, you have many opportunities to choose plans that best suit your needs and your budget. Enrolling in Original Medicare (Parts A and B) and then selecting a stand-alone Medicare Part D plan allows you to choose a prescription drug plan that better meets your prescription drug and financial needs. Some plans offer a broader list of covered medications, cost-saving preferred pharmacy networks and/or convenient home delivery.

A Medicare Advantage Plan with prescription drug coverage can offer the convenience of having all of your health and prescription coverage bundled under one provider. However, this convenience may result in less choice and less opportunity to ensure the plan meets all of your prescription drug needs.

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I’m turning 65 later this year. When can I enroll in Medicare Part D?

Key Dates for Medicare Annual Enrollment Period


Plan information available:

October 1

Enrollment begins:

October 15

Enrollment ends:

December 7

Note: The late enrollment penalty is 1% of the national average premium for every month you were without Part D prescription drug coverage or other creditable prescription drug coverage following your initial enrollment period, or if you had a break in creditable prescription drug coverage of 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare’s standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Part D coverage.

If you are turning 65 later this year and need prescription drug coverage for the remainder of the year, you should begin researching plans that offer Part D coverage now. You have an initial enrollment period that lasts 7 months. You can enroll up to 3 months before your birth month, the month of your birth, and up to 3 months following your birth month. In general, you can begin researching plans for the following year on October 1 when plan details become available.

What is Medicare Supplement Insurance?

Medicare Supplement Insurance, also called Medigap, are plans offered by private companies that help cover some costs not paid by Original Medicare (such as deductibles and copayments). There are 10 supplemental plans that offer a variety of additional options. Get more information on choosing the right Medicare plan here.

Who can I call to discuss my various Medicare options?
  • Discussing your Medicare options with someone knowledgeable can help you understand them completely and will help you to identify other important considerations when selecting a plan.
  • Many plans offer Medicare advisors who can answer questions about the plan and help you determine if the plan will meet your needs. Calling the plan before you enroll is a good way to determine how the plan will treat you in the future.
  • You can also speak with a licensed insurance broker/agent free of charge.  If you are losing employer-provided prescription drug coverage, your employer may make these services available to you. Additional resources you can turn to include Medicare.gov, the Medicare & You handbook and your State Health Insurance Assistance Program (SHIP).
  • Medicare prohibits door-to-door sales without your previous permission or a scheduled appointment. If someone comes to your home without an appointment to sell a Medicare plan, turn him or her away and report the person to the Department for Health and Human Services.
  • Lastly, you can discuss your options with Medicare by calling at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877‑486‑2048.
What is a Medicare Part D deductible?

A deductible in a Medicare Part D plan is similar to a deductible in other types of insurance. For example, following an accident, your car needs $2,000 worth of repair. Your auto insurance policy has a $500 deductible. This means you pay the first $500, and your insurance pays the rest ($1,500).

In Medicare Part D, the deductible is the amount you are required to spend out of pocket on your medication before your coverage begins. So, if the plan you choose has a $50 deductible and your first prescription costs $75, you will pay $50 and the plan will pay $25. Once you’ve paid the deductible amount, you will be responsible only for the copayment or coinsurance required on future prescriptions.

Not all Part D plans have a deductible. Some plans with a higher monthly premium will offer a low or $0 deductible. Plans with lower or no monthly premiums may have a higher deductible. Learn more about Medicare plan costs here.

Where can I find information on the drugs covered under Medicare Part D plans?

Each Medicare Part D prescription drug plan (PDP) has its own list of covered drugs. This is called a formulary. You can find out which specific medications are covered by looking at the drug list (formulary) included on Medicare.gov or through a Part D plan’s enrollment materials that you can review online or request through the mail.

How much should I expect to pay in copayments with a Medicare Part D plan?

Every Medicare Part D prescription drug plan (PDP) will have a different formulary (drug list). Within a formulary, many Part D plans will sort drugs into cost-sharing “tiers.” Typically, plans have 4 or 5 tiers (or levels) and each tier includes different medications. Your plan will determine what your copayment or cost-share is for each tier. Every plan is different. A drug in a lower tier will cost less than a drug in a higher tier. Often, generic medications will fall into tiers 1 and 2. Brand-name and specialty medications will be in higher tiers. Your doctor may ask for a “tiering” exception if your drug is on a higher tier and cannot be substituted with a similar drug on a lower tier.

Can I still use my pharmacy if I choose a Medicare Part D plan whose pharmacies offer “preferred” pricing?

One way Medicare beneficiaries can reduce prescription drug costs is to choose a Part D plan whose pharmacy networkoffers both preferred and standard pricing. Within a broad pharmacy network, certain pharmacies will offer lower copayments, also known as “preferred cost-share.” At those pharmacies, you will pay a lower share of the cost of the drug than you would if you filled the prescription at another network pharmacy offering “standard” pricing (or “standard cost-share”).
 
If using a specific pharmacy is important to you, check with the plan before you enroll to see if your pharmacy is in its network and, if so, if it offers preferred pricing.

Are there ways to avoid the Coverage Gap?

There are ways to effectively delay reaching the Coverage Gap or “donut hole.” You enter the Coverage Gap when your total prescription costs (your deductible and copayments in the initial coverage stage plus what the plan pays) exceed the amount set by Medicare each year. The best way to delay reaching the gap is to keep your pharmacy costs down. Here are some ways you can do this:

  • Use generic medications when available and appropriate for you. Generics cost a fraction of the price of their brand-name counterparts, and many Medicare Part D prescription drug plans (PDP) offer $0 or low copayments when you use a generic medication. Talk to your doctor or call your plan and ask for help in finding lower-cost alternatives for your brand-name medications.
  • Take advantage of a home delivery pharmacy for your long-term medications and use a preferred pharmacy when possible. Choosing a preferred pharmacy helps to lower your costs.

 

What are Medicare Part D Star Ratings? Are they important?

Medicare created the Star Ratings system to help you compare quality and performance among Medicare Part C (Medicare Advantage) plans and Medicare Part D prescription drug plans (PDPs). Medicare determines the ratings each year, evaluating a plan’s performance in more than 50 areas across 4 broad categories. These categories range from customer service to patient safety. Medicare assigns them a rating of 1 to 5 stars. This provides a current and unbiased measurement of a plan’s overall performance.

Star Ratings are an important factor to consider when choosing a plan. They take the guesswork out of selecting a trustworthy plan by telling you if the plan is likely to offer high quality.

In general, you should look for plans with a rating of 3 to 5 stars. At Medicare.gov, you can view the details of a plan’s Star Rating to see how well it performs in each category. If the plan you like has low ratings, review the Star Ratings details to make sure it’s a good choice for you.