Medicare Part D Coverage

Private insurance companies provide Part D, Medicare Prescription Drug Coverage, to anyone who signs up for Original Medicare. Part D coverage can be added during your 7-month Initial Enrollment Period. Most Part C (Advantage) Plans include Part D coverage. Advantage Plans that do not provide prescription drug coverage can also be used with Part D policies.

In order to qualify for a Part D Plan you must be enrolled in Part A or Part B through Original Medicare or through an Advantage Plan.

Premiums for Part D are determined by modified gross adjusted income. A small percentage of people will be charged higher rates for a Part D plan based on their income. Deductibles and co-payments are also part of these plans. Costs for coverage often fluctuate and change every year.

Most Medicare Part D coverage has what is known as a coverage gap. Also called the "donut hole". The gap refers to a temporary halt on what the insurance company will pay after you have reached a certain amount in prescription drug spending. When this happens you will get your prescription drugs at a 50% reduced rate but you will have to pay all the costs as part of your out-of-pocket expenses. If you use generic drugs they will give you an additional 7% savings. Once you reach the limit on your out-of-pocket expenses the coverage gap will end and you will only pay a small co-payment for prescriptions.

Each Medicare Part D Plan has a different list of drugs included in their coverage. Part D plans must cover all commercially available vaccines not covered by Medicare Part B. This list is often called a "formulary" and the drugs will often be listed according to tiered coverage. Pay attention to this list because more expensive drugs might be covered at a different rate. If your doctor has a good reason for wanting the higher tiered drug he/she can ask for an exception and you might be able to get that drug at the lower rate. Over time this can make a substantial difference in what you pay for drug coverage.

Auntie Lou says, "Read the list called the formulary and make sure it isn't a formula for disaster."

Coverage for prescription drugs also includes a variety of other rules that have been established to keep costs down. For example, prior authorization from the insurance policy is needed before you fill certain prescriptions. The quantity of drugs you can get each time can be limited and the plan may ask you to submit to step therapy where you try less expensive drugs for a while and see how you react to them. You and your doctor can always ask for an exception to waive these types of rules.

Extra Help is available through Medicare for individuals who have trouble paying for Part D coverage. Help for paying for prescription drugs is also sometimes available from state, private charitable organizations and prescription drug companies. To see if you qualify for Extra Help contact Medicare at 1-800-MEDICARE.