What Does Medicare Part D Cover?

When you enroll in Medicare Part D, you’ll have the opportunity to select a private insurance plan that works with Medicare. Each plan offers its own list of covered drugs, known as a formulary, and you’ll have the choice between brand name and generic medications. It’s important to note that these formularies can vary from year to year, so it’s crucial to review your coverage annually to ensure that it still meets your needs.

Medicare Part D covers a wide range of drugs including:

• Antidepressants
• Anticonvulsants
• Antineoplastics (cancer drugs)
• Antipsychotics
• Antiretrovirals (HIV/AIDS drugs)
• Immunosuppressants

However, Medicare Part D doesn’t cover many popular types of prescription medications, leaving some beneficiaries struggling to afford the treatments they need. Among the excluded drugs are over-the-counter medications, weight loss drugs, fertility treatments, cosmetic prescriptions, and certain prescription vitamins and minerals. Additionally, some life-enhancing medications, such as erectile dysfunction drugs and sleep aids, are also not covered.

In some cases, you might be able to request coverage for a drug not listed on your plan’s formulary through an exceptions process. If your doctor believes a specific medication not covered by your plan is medically necessary, they can submit a request for an exception.

How Much Does Medicare Part D Cost?

The cost of Medicare Part D varies based on several factors, such as the plan you choose, the drugs you take, and whether you enter the coverage gap. Below are the costs to be aware of when enrolling in a Medicare Part D plan:

Monthly premium: You’ll need to pay a monthly premium for your Part D plan, which may vary depending on the plan you choose. If your income is above a certain threshold, you may also be required to pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to your premium.

Annual deductible: Some plans have an annual deductible, which is the amount you must pay out-of-pocket before your plan begins to cover your prescription costs. Deductibles can vary among plans, and some may not have a deductible at all. The maximum deductible you would have to pay in 2023 is $505.

Initial coverage: Once your plan begins to cover your prescriptions, you’ll be responsible for copayments (fixed dollar amounts) or coinsurance (a percentage of the drug’s cost) when you fill your prescriptions. These amounts may vary based on the tier of the drug in your plan’s formulary. Once you and your plan have spent a total of $4,660 on covered drugs in 2023, you’ll enter the next phase.

Coverage gap (Donut Hole): The coverage gap, or “Donut Hole,” is a temporary limit on your plan’s coverage for prescription drugs. While in the coverage gap, you’ll pay 25% of the cost for both brand-name and generic drugs. Once your total out-of-pocket costs (excluding premiums and the cost of non-covered drugs) reach $7,400, you’ll exit the coverage gap and enter catastrophic coverage.

To reduce costs in the coverage gap, consider the following strategies:

• Use generic drugs whenever possible, as they usually cost less than brand-name drugs.
• Ask your healthcare provider about therapeutic alternatives that may be more cost-effective.
• Utilize your plan’s preferred pharmacy or mail-order options for lower out-of-pocket costs.

Catastrophic coverage: Once you’ve spent $7,400 out-of-pocket, your plan’s catastrophic coverage kicks in. During this phase, you’ll pay a small copayment or coinsurance amount for your covered drugs for the remainder of the year.

It’s important to review the details of any plan you are considering. That way you can be sure you understand the costs and ensure that it meets your healthcare needs at an affordable price. It’s also advisable to speak with a licensed insurance agent. They possess the expertise to guide you through the intricacies of various Medicare Part D plans and identify the best one for your specific needs and circumstances.

Medicare Part D Eligibility

Medicare Part D is a program that provides prescription drug coverage to beneficiaries. However, not everyone is eligible for this program. Knowing the eligibility requirements can save you time and money in the long run, and ensure you have access to the medications you need.

Eligibility Requirements for Medicare Part D:

• Be enrolled in Medicare Part A.
• Be a U.S. citizen or permanent legal resident.
• Be aged 65 or older or have a qualifying disability.
• Live in the service area of the Medicare Part D plan.

Be sure to speak to a licensed insurance agent if you have any questions regarding eligibility.

Medicare Part D Enrollment Deadline

As a Medicare beneficiary, it’s crucial that you stay informed about important dates related to Medicare Part D enrollment. Missing these deadlines could leave you without prescription drug coverage or result in penalties. To ensure that you’re well-prepared, let’s dive into the key dates and tips you need to keep in mind.

• Initial Enrollment Period (IEP): Your IEP is a seven-month window that starts three months before the month you turn 65, includes your birthday month, and ends three months after your birthday month. If you’re eligible for Medicare due to disability, your IEP begins three months before your 25th month of receiving Social Security or Railroad Retirement Board disability benefits and lasts for seven months.
• Annual Enrollment Period (AEP): The AEP, also known as Open Enrollment, runs from October 15th to December 7th every year. During this time, you can enroll in, switch, or drop a Medicare Part D plan. Any changes you make will take effect on January 1st of the following year.
• Special Enrollment Period (SEP): If you experience certain life events, such as losing employer-based coverage or moving to a new location, you may qualify for an SEP. These periods allow you to enroll in or change your Medicare Part D plan outside of the regular enrollment periods. The length of an SEP varies depending on the circumstances.

Failing to enroll in Medicare Part D during your IEP can result in a late enrollment penalty, which is added to your monthly premium for as long as you have Part D coverage. This penalty is calculated as 1% of the “national base beneficiary premium” multiplied by the number of months you were without creditable prescription drug coverage. To avoid this penalty, make sure to sign up for a Part D plan during your IEP or maintain creditable drug coverage through another source, like an employer or union.

If you already have prescription drug coverage, review your plan’s Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents, which you should receive each fall. These documents will detail any changes in costs, coverage, or the pharmacy network for the upcoming year. Use this information to assess whether your current plan still meets your needs or if it’s time to consider other options during the AEP.

How To Sign Up For Medicare Part D

Signing up for Medicare Part D involves a few simple steps:

1. Research and compare Medicare Part D plans. Simply enter your zip code to see plans that are available in your area. You can easily filter the results by company, premium and policy type.
2. Once you find a plan that meets your needs, contact the insurance company offering the plan to enroll. You can do this by calling the company directly or visiting their website. Make sure to have your Medicare card and personal information handy when enrolling.
3. After you’ve successfully enrolled in a Medicare Part D plan, you’ll receive a new membership card and information about your plan’s benefits, coverage, and provider network.

By following these steps, you can successfully sign up for Medicare Part D and secure the prescription drug coverage you need. Make sure to present your membership card when filling prescriptions at your chosen pharmacy. It’s also advisable to keep track of all your drug expenses and be aware of any changes in coverage or formulary.

How To Get Help With Medicare Part D

Don’t navigate the complexities of Medicare alone. Our licensed agents at Senior Healthcare Solutions are here to help. Call us today at 866-MEDIGAP (866-633-4427) for fast and reliable assistance from knowledgeable Medicare experts. We’re here to ensure that you have the peace of mind that comes with knowing you’re making informed decisions about your healthcare coverage. So, contact us today and let us assist you every step of the way.

Frequently Asked Questions