Medicare Part D
Medicare Part D is a prescription drug plan (PDP) offered to anyone who has Medicare Part A and/or is eligible for Part B.
There are 3 methods of obtaining prescription drug coverage:
- Medicare Part D that can be added to original Medicare (to complement a Medicare Supplement).
- Prescription coverage that is usually part of most Medicare Advantage plans (such as a Medicare-HMO or Medicare-PPO). These plans are referred to as “MA-PDs”.
- Medicare Part D that can be added to certain Medicare Advantage plans (such as some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Medicare Part D Prescription Drug Plans (PDP) are administered by insurance companies that are contracted with Medicare. BUT, not all PDP’s are the same! They may vary by company in several ways:
- Premiums that you would pay
- Deductibles
- Copays
- Coverage in the “Donut Hole”
- Formulary
Here’s how Formularies may vary:
- Each PDP has its own list of drugs that they will cover. A medication that exists on one company’s formulary may not be on another company’s formulary!
- Each company has “tiers” such as “preferred generic”, “generic”, “preferred brand”, “non-preferred brand”, and “specialty”. Deductibles, co-pays and/or co-insurance may vary for each tier for each company.
What does a Part D Prescription Drug Plan (PDP) cover?
Every PDP has a formulary which lists the drugs that it covers and what ‘tier’, or level, the drug may fall into. Each tier has its own co-pay. Drugs in a lower tier will cost you less than in a higher tier.
Not every company will cover every prescription for your situation. For example, company “A” may cover Lisinopril for hypertension whereas another company may not cover Lisinopril and in its place, choose to offer a substitute drug of equal quality.
In addition, as a way of controlling costs, some companies may recommend a “step therapy” which basically means that if your doctor prescribes an expensive brand name, the plan may suggest trying a less expensive generic first. In most cases, if that generic doesn’t prove to be effective, your doctor can request an exception to be made and the higher cost drug would be allowed.
If you choose a particular Prescription Drug plan does not meet your needs, you can always choose a new one during the next Open Enrollment period.
Because PDP plans can vary from region to region and even county to county, we recommend that you speak to an independent insurance agent during Open Enrollment time to help you choose the one that will best suit your needs and affordability.
Questions or would like further information? Please feel free to call me at (910) 775-0700 for a FREE consultation!