Understanding how all the parts of Medicare coverage work can be challenging to understand at first. Medicare Part D may be one of the most challenging because of the wide variances in coverage and costs from one plan to another. Here’s what you need to know to understand how Medicare Part D coverage works.
Medicare Part D is the prescription drug benefit component of Medicare. It must be added on to Original Medicare (Part A or B) or it can be included as part of a Medicare Advantage Plan.
Medicare Part D coverage is offered through insurance and other private companies that have been approved by Medicare. Based on the individual plan, it covers a variety of brand name and generic prescription drugs, as well as some over the counter medications.
Medicare Part D provides beneficiaries with various plan options, allowing you to choose the plan that best meets your needs.
There are many factors to consider when selecting a Medicare Part D Prescription Drug Plan. The Centers for Medicare and Medicaid Services recommends comparing the following when selecting a plan:
All plans will include coverage for brand name and generic drugs within different drug classes; however, each plan varies on the specific medications it will cover. These lists of covered medications are called formularies [link to formularies blog] and each plan has it’s own formulary.
If you already take medication you’ll want to ensure your plan covers the prescriptions you’ll need. If you currently do not take medication, you’ll want to think about the future - you may anticipate needing medication in the future or you may just want to protect yourself from higher copays in the event that you fall ill.
There are a few options you can pursue if you’re ideal plan doesn’t cover your existing prescriptions. You can read more about that here [link to formulary blog].
Each plan has a different monthly premium. The Medicare Plan Finder Tool allows you to view and compare various plan premiums within your service area. You can also view the anticipated costs of specific medications within each plan.
Plans have preferred pharmacies. Make sure to compare the pharmacy locations covered by the plans you are considering.
In addition to the distance to the pharmacy, don’t forget to consider their hours of operation as well.
Some plans also allow for mail order, which may be more convenient than traveling to a physical pharmacy to pick up your prescriptions.
Plans also have service areas. If you are a “snowbird” or frequent traveler, make sure the plan you select will cover you in the locations you stay in for extended periods.
The Medicare Plan Finder Tool provides customer ratings on a 5-star scale. You can view overall ratings for individual plans in terms of customer service, complaints and changes in the drug plan’s performance, experience, and drug safety and accuracy of drug pricing.
Most plans charge a monthly premium. The monthly premium varies across plans and is charged in addition to the Part B premium. Medicare Advantage and Medicare Cost plans may have a monthly premium that includes an amount for prescription drug coverage.
Based on your reported income you may be subject to an Income-Related Monthly Adjustment Amount (IRMAA). This adjustment amount will be added to your monthly premium. Social Security will notify you by mail if your income is subject to an IRMAA.
The plan you choose may or may not charge a yearly deductible. If it does, you’ll have a set amount you’re required to pay for your medications before your plan begins paying. In 2020, the yearly deductible cannot exceed $435.
Copayments (also called coinsurance) are the amount you pay for your drugs after you reach your yearly deductible. The copayment is calculated by subtracting the amount your plan pays towards a specific drug from the total amount of the drug.
During the year you may enter the Coverage Gap or “Donut Hole [link to donut hole blog].”
This happens when you and your plan reach a nationally set spending threshold.
Because of recent legislation, the coverage gap is closing. This means you won’t have to pay entirely for your prescriptions while in the coverage gap. Your plan will continue paying a portion of both brand name and generic prescriptions until you leave the coverage gap.
Your plan will send you an Explanation of Benefits (EOB) each month you have a prescription filled letting you know how close you are to reaching the coverage gap.
In 2020 the threshold to enter the coverage gap is $4,020 and $6,350 to leave the coverage gap. In addition, while in the coverage gap drug manufacturers will give a 70% discount, and plans will pay 5% on covered brand name drugs and 75% on covered generic drugs.
Catastrophic Coverage isn’t as scary as it sounds. Catastrophic Coverage kicks in immediately once you leave the Coverage Gap. Catastrophic Coverage significantly lowers your copayments for the rest of the year.
Medicare Part D Coverage has a lot of eligibility qualifications [link to eligibility blog] and options to consider. Making the right choice is crucial to your health care plan. The team at Plan Advisors is expertly trained in all aspects of Medicare coverage to help you make the most informed decisions. The first choice is easy - reach out to a trusted Medicare advisor to get started today!
Your time is valuable. Who would want to spend time going to pick up the prescriptions from the pharmacy if you didn’t have to, right?
Well you’re in luck! Most Medicare plans offer a time-saving alternative to having to drive to the pharmacy to get your prescriptions.
With mail-order pharmacies you can enjoy the convenience of using your Medicare Part D drug plan from the comfort of your home.
Most health insurance plans either have their own mail-order pharmacy programs, such as Humana Mail Order Pharmacy, or partner with trusted pharmacies, such as CVS, to provide mail-order pharmacy benefits for qualified Medicare recipients.
In addition to having your maintenance meds delivered right to your door, there are other advantages to using your plan’s mail order pharmacy benefit.
When you enroll, you can gain peace of mind with:
And of course there’s the time savings!
If you live more than 15 minutes away from your local pharmacy or utilize transportation assistance, getting to and from the pharmacy can be very time consuming.
It’s pretty clear mail-order pharmacy services are worth considering.
Understanding how all the parts of Medicare coverage work can be challenging at first, but there are plenty of resources if you need help understanding Medicare Part D coverage or learning how to find the right Medicare Part D coverage.
And getting enrolled in a mail-order pharmacy program is pretty simple.
Signing up for home delivery prescription programs varies by carrier.
For most carriers you can register online, complete a mail service order form, or call the number on your member ID card.
It’s that simple!
To make sure your prescriptions are available through the mail-order program, you can search printed formularies (drug lists) from your pharmacy, utilize online prescription look-up tools, or simply pick up the phone and call to ask the pharmacy.
The easiest way to get your prescriptions submitted for mail-order services is to have your doctor electronically send the prescription to the pharmacy using an e-prescription.
Of course, you can also have your physician send a physical prescription form to the pharmacy as well.
Plenty of Medicare carriers offer mail-order pharmacies.
Click on the links below for mail-order pharmacy enrollment information on each of the carriers:
But that’s not all.
BlueCross BlueShield also offers mail-order pharmacy services; though these services vary by state. Additionally, you can get mail-order prescriptions with Solis, simply call 888-240-2211 to learn more.
Save a monthly trip to the pharmacy (and potentially a few dollars) with the mail-order option.
Just think of what you can do with all that free time.
Need help navigating your Medicare Part D benefits? Find an advisor who can help you make sure you're getting the most out of your prescription drug plan.
As we age, our health needs change, and older adults, especially, face many challenges when it comes to taking care of their health. Among the most challenging is navigating the government-sponsored healthcare coverage program for seniors. The golden years of retirement can be overshadowed by the bombardment of telephone calls and excess junk mail all about Medicare. It’s no wonder so many older adults get confused when it comes to making the right choices for their healthcare coverage and therefore rely on outside help.
About 19% of Americans act as caretakers for a spouse, parent, grandparent, or community member; and the majority of individuals being cared for rely on Medicare or Medicaid. Even adult children whose parents and grandparents are still independent often end up helping their loved one navigate the healthcare system.
One of the first steps to being able to help your parent, grandparent, or other loved one enroll in Medicare is to understand the process. Keep reading to learn more about the different parts of Medicare, how Medicare enrollment works, and how to find the Medicare plan that best fits your loved one’s needs.
Medicare is a complex system that can be difficult to fully understand, especially when there is a wealth of information available. We’ll start simple by defining Medicare and all its basic parts.
Medicare is the U.S. government’s largest health insurance program that provides affordable healthcare coverage to eligible adults. With Medicare, there are a few different options for how to get coverage.
Medicare Parts A and B, or Original Medicare, offer hospital coverage and outpatient coverage respectively. Part A pays for room and board at the hospital and some other healthcare facilities. Part B includes almost everything that Part A doesn’t cover, like doctor visits, medical equipment, lab work, surgeries, therapy, and more.
With Original Medicare, the recipient pays for services as they get them. While Medicare will cover a lot of costs, your loved one could still be responsible for deductibles, copayments, and coinsurance. However, they may also be eligible for Medigap, supplemental insurance, to help cover those costs. If your loved one needs prescription drug coverage, they can also apply for Medicare Part D.
Medicare Part D provides coverage for prescription drug costs. This plan is offered by private insurance carriers and is available for purchase as a separate stand-alone plan for those with Original Medicare or can also be included as part of a Medicare Advantage plan.
Medicare Part C, or Medicare Advantage, is an optional, low-cost alternative to Original Medicare offered by private, Medicare-approved insurance companies. These “all-in-one” plans bundle Medicare coverage, including Parts A and B and usually Part D prescription drug coverage as well. Medicare Advantage can also cover things that Original Medicare does not, like vision, dental, and hearing insurance.
A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs that Original Medicare does not cover. This may include copayments, coinsurance, and deductibles. Not everything falls under Medigap, however. A supplement plan may not cover long-term care, vision or dental care, hearing aids, eyeglasses, or private-duty nursing. Medicare Supplement plans are offered by private insurance carriers.
There are multiple Medicare enrollment periods that your parent or loved one may be eligible for. Individuals become eligible for Medicare when they turn 65. Younger adults who are disabled or have End-Stage Renal Disease may also be eligible for Medicare.
It is important to do your research and know the date cutoff for their enrollment period in order to make sure they are enrolled without any penalties.
Initial Enrollment Period: IEP begins three months before your 65th birthday and ends three months after the month that you turn 65. In most cases, if you don’t sign up for Medicare Part B when you’re first eligible, you will have to pay a late enrollment fee for as long as you have Part B and could have a gap in your health coverage.
Annual Enrollment Period: AEP begins October 15 and ends December 7 each year. During this time, beneficiaries are able to make changes to their existing Medicare plans.
Open Enrollment Period: OEP allows beneficiaries to make a one-time change to their Medicare Advantage Plan from January 1 through March 31. During this time, you can also sign up for Medicare if you missed your window, but fees and gaps in coverage may apply.
Special Enrollment Periods: SEPs are available under certain circumstances throughout the year, such as moving out of your existing plan’s service area or retiring from a job that previously provided your benefits. Generally, there are no late fees associated with signing up for Medicare during an SEP, but the eligibility requirements vary.
There are pros and cons to each Medicare plan, but the most important thing is to find the plan that best fits your parent or loved one’s needs. Determining this will depend on a few factors unique to their circumstance, such as where they live and what kind of care they expect to need.
Here are a few other things to consider:
Cost: How high will the beneficiary’s out-of-pocket expenses be? This could include monthly premiums, deductibles, copayments, or coinsurance.
Benefits: Does the plan cover any additional healthcare services they need? For example, prescription drugs, vision, dental, or hearing insurance.
Convenience: Are the in-network providers conveniently located? Are their preferred healthcare providers in-network?
Needs: Have they required healthcare in the past few years? Do they anticipate an increased need for care? Do they often see specialists for a health condition?
All of these factors impact which plan is right for your loved one. And often two plans can seem very similar, yet the smallest difference can dramatically change their fit.
To make sure you get it right the first time, your best option may be to discuss your parent or loved one’s situation with a Medicare advisor. A professional can help you weed through the excess information and find the exact plan that will best serve your loved one.
If you're helping a loved one or parent enroll in Medicare our experienced Medicare Advisors are here to support you if you have a question. You can also explore more of our Medicare Resources to educate yourself on all things Medicare.
Reaching retirement age can be an exciting stage of life, but it can be overwhelming to navigate changes in your insurance coverage. Medicare is the government health insurance program that provides healthcare coverage for individuals 65 and older. Medicare Part A and Part B provide hospital and medical insurance, but what about drug coverage? Medicare Part D is the prescription drug benefit component of Medicare. Based on the individual plan, it covers a variety of prescription drugs, as well as some over the counter medications.
To find out if you are eligible for Medicare Part D, you first need to determine if you are eligible for Original Medicare (Parts A and B).
You are eligible for Original Medicare if any of the following qualifications are met:
Once you become eligible and enroll in Medicare Part A and/or Part B, you become eligible for the Medicare drug benefit (Part D).
Worried about being denied coverage because you have high blood pressure, take multiple medications daily, or are a smoker? Like Original Medicare, Medicare Part D is available regardless of pre-existing or future health conditions.
Just because you are eligible for a Medicare Prescription Drug Plan, doesn’t mean you’re required to have one. However, it is important to consider at the time you first become eligible for Medicare to avoid a lifetime late enrollment penalty and gaps in coverage in the future.
Whether you receive prescription drug coverage from Veterans Affairs Benefits, TRICARE for Life, Federal Employee Health Benefits, or other job-based or retiree plans; The Medicare Modernization Act (MMA) requires these entities to notify Medicare eligible policyholders if their prescription drug coverage is creditable coverage before October 15th each year. Creditable coverage simply means that the coverage is expected to pay approximately the same amount as the standard Medicare prescription drug coverage.
If you’re unsure if your current prescription drug coverage is considered creditable, reach out to your benefits representative to find out. It’s important to do this as soon as possible because if you go more than 63 days without creditable coverage before signing up for a Medicare Part D Plan, you will be charged a lifetime penalty.
But don’t worry — if your creditable coverage ends or changes in the future you will receive a two-month Special Enrollment Period (SEP) to enroll in a Part D plan, penalty- free.
If you do not have other Creditable Coverage, you have two options to receive prescription drug benefits:
Now that you have determined you are eligible for Medicare Part D, there is one more eligibility requirement you need to consider.
Once you have enrolled in Original Medicare or a Medicare Advantage Plan, there is one more eligibility requirement you must meet, depending on which plan you choose. Each prescription drug plan requires that you live in that plan’s service area.
If you move to another service area during your plan year, you will receive a Special Enrollment Period (SEP) and can enroll in a new plan that is available in your new region.
While different plans may cover different prescriptions or may include additional benefits, Medicare requires all plans provide the same basic level of drug coverage.
Just because pronouncing the name of your prescriptions is challenging doesn’t mean that navigating Medicare Part D coverage should be too. Plan Advisors is here to help you find the plan that works best for you. Reach out to a local Plan Advisor to get started today.
The process of comparing Medicare Part D prescription drug plans can be stressful. Luckily, the U.S. Centers for Medicare & Medicaid Services has created a Medicare Plan Finder Tool that can help you find plans available in your service area and compare plan details, such as formularies and costs, side by side.
Each Medicare Part D plan has its own unique list of preferred drugs called a formulary. A Medicare Part D formulary can include both name brand and generic medications. Carriers have the ability to choose which specific drugs each of their plans will and will not cover.
Federal law requires every Medicare Part D plan to cover at least two drugs in each class of drug category on their formulary. Most plans will cover more than two drugs in each class. This means that even if your current medication isn’t on the formulary, it’s highly likely that a comparable medication is covered.
All Medicare Part D plans are also required to cover nearly all drugs within six drug classes on their formulary:
Additionally, between your Medicare Part B coverage and whichever Part D plan you choose, all commercially available vaccines will be covered, including flu, pneumonia, and shingles.
To keep your copays low, many plans organize the prescription drugs on their formulary into tiers. Tier 1 will usually include most generic medications at the lowest cost to you. Tiers 2-5, which may include a “specialty” tier, will include preferred and non-preferred brand name prescriptions at higher copays.
Medicare imposes various utilization management rules to ensure that medications are being used properly. These rules include:
Generally, all Medicare Part D plans have a list of medications that they are not allowed to cover or may offer as an additional premium benefit. These include medications for weight management, fertility, erectile dysfunction, and non-prescription drugs, vitamins, and minerals. If your plan does not cover the medication you’ll likely have to pay out-of-pocket.
If your doctor prescribes you a medication not covered by your plan, you still have options. If the utilization management rules aren’t effective for your treatment plan and your doctor feels that a drug not covered by your plan is medically necessary, they can file for an exception, sometimes referred to as a coverage determination. Your plan or pharmacy can assist you in obtaining the paperwork to file an exception.
You should also be aware that Medicare Part D plans have the ability to make changes to their formulary during the year as long as they follow certain guidelines.
Medications may be immediately removed from a plan’s formulary if it is recalled from the market by the Food and Drug Administration because it is deemed unsafe, or if a drug manufacturer discontinues production of the drug.
The introduction of a new generic medication can also impact your formulary throughout the year. New generics may replace existing brand name medications, or the brand name medications may be pushed up to a higher tier.
If your plan decides to make any other formulary changes throughout the year they are required to notify you at least 30 days before the change happens.
At the beginning of this article, we mentioned the Medicare Plan Finder Tool offered by the U.S. Centers for Medicare & Medicaid Services. Though this tool is designed to help consumers make educated decisions about their Medicare benefits, issues with the Plan Finder tool have been reported.
To make sure you have the most complete, up-to-date Medicare Part D formulary information, schedule a time to meet with a Plan Advisor team member. Our advisors can help ensure you make the best plan decision to fit your needs.
Donuts are a great sweet treat - unless you’re a Medicare Part D beneficiary. Medicare Part D beneficiaries have been dealing with the donut hole since the Medicare Part D program began in 2006. However, recent legislation through the Affordable Care Act has made your time in the donut hole a little easier to digest.
The Affordable Care Act was passed in 2010 and is a comprehensive health care reform law, sometimes referred to as “Obamacare.” Some of the major goals of the ACA are:
The Affordable Care Act also requires insurance plans to cover certain preventative care, which is why all commercially available vaccines are available to all beneficiaries through their Medicare Part B and D plans.
The donut hole isn’t as sweet as it sounds when it comes to Medicare Part D prescription drug coverage. The donut hole refers to a coverage gap most Medicare Part D beneficiaries are subject to each year.
This means that once a certain spending threshold has been reached for covered medications, you will have to pay more out-of-pocket for your prescriptions until you reach the yearly limit. Once you reach the yearly limit, your plan will begin paying for covered drugs again.
Nervous about unexpectedly entering the donut hole? Your Medicare Part D drug plan will mail you an Explanation of Benefits (EOB) notice each month you fill a prescription, letting you know your progress towards meeting the donut hole threshold.
You may have heard that the Affordable Care Act is closing the Donut Hole. While this is true, it can also be a little misleading.
In this case, closing doesn’t mean going away altogether. Instead, it simply means that the cost that Medicare beneficiaries pay is decreasing.
Over the past 10 years, the percentage that Medicare beneficiaries pay in the donut hole annually has been shrinking, while the percentage your Medicare plan and the drug manufacturer pays has been increasing.
For 2020, once you are in the Donut Hole, your plan will still cover a minimum of 5% of your brand name medication costs and you’ll also receive a 70% discount from the manufacturer. Medicare will also pay 75% of the cost of generic medications. Therefore, you will only be responsible for 25% of the cost for both brand-name and generic medications on your plan’s formulary while in the donut hole.
The donut hole threshold is predetermined annually and does not vary between Medicare Part D prescription drug plans. It also takes into account what you pay and what your plan pays toward covered medications.
For 2020, once you reach $4,020 you will enter the donut hole.
While the threshold amount does not vary, each plan will have a different premium and expected monthly drug costs that will affect how quickly you enter and leave the donut hole. It is important to compare this information when choosing a plan.
The Medicare Plan Finder Tool , provided by the U.S. Centers for Medicare & Medicaid Services, allows you to search your current medications and determine the retail cost, costs before and after you meet your deductible, and your costs while in and after leaving the donut hole. Discrepancies, though, have been found within the tool.
Working with a trusted Medicare advisor can make understanding this information easier and help you make the right choice when selecting a Medicare Part D prescription drug plan. Schedule a meeting with Plan Advisors team member to learn more about the Medicare Part D donut hole and how you can get the right plan for your needs and budget.
Need a Medicare Part D prescription drug plans, but don’t know where to start? The U.S. Centers for Medicare & Medicaid Services recently redesigned their Medicare Plan Finder tool to make shopping for a Medicare Part D Plan as simple as possible.
You can log in to your Medicare account for a more personalized experience, or if you’re new to the Medicare market you can follow these easy steps to get started:
If you are looking only for Medicare Part D Prescription Drug Plans, you will select “Drug plan (Part D)” and enter your zip code to view only plans that are available in your service area. You can also explore Medicare Advantage Plans and Medigap policies.
If you receive Medicare cost assistance from Medicaid, Supplemental Security Income, Medicare Savings Program, or Extra Help from Social Security, you’ll want to select the applicable program before moving forward. If you do not receive Medicare cost assistance you will select “I don’t get help from any of these programs.” If you are unsure, Medicare may be able to help you find out if you create an account.
Adding your drug information to your search can be beneficial when comparing plans. If you currently take medication you’ll want to ensure you add the drug by either the brand-name or generic name - whichever you take. You will then want to make sure you select the correct dosage, quantity, and frequency the medication is filled. It is important to inout this information as accurately as possible to get the most accurate plan details.
You can also choose how you typically have your prescriptions filled - retail pharmacy (Walgreens, CVS, Walmart, local pharmacy, etc.) and/or mail order pharmacy. You will then be able to select your preferred pharmacy or compare pharmacies you are considering using. Not all plans will be in-network and plan pricing may vary by pharmacy. You can compare up to 3 pharmacies at once.
Now you will be able to see all plans that are available in your service area and at the pharmacies you selected. You can filter the results to show plans that are accepted across the U.S. (important for travelers), and by plan star ratings and insurance carrier. You also have the option to sort the available plans by lowest monthly premium, lowest yearly drug deductible, or by lowest drug and premium cost.
Each plan will display the insurance carrier, plan name, plan ID, star rating, monthly premium, drug deductible, pharmacy estimated total drug and premium cost on the overview page.
To view a full plan profile you can select “Plan Details” for the plan you are interested in. Here you will find the drug costs for different drug tiers during the initial coverage phase, gap coverage phase, and catastrophic phase. You will also be able to see the costs for the specific medications you entered into the Plan Finder, as well as any prior authorization, step therapy, or quantity limits required by the plan. Contact information is also available here.
Like with pharmacies, you can compare up to 3 plans at once by selecting “Add to compare.” This option will allow you to compare multiple plans, along with your previously selected pharmacies, side by side.
The Medicare Plan Finder has made comparing Medicare Part D Prescription Drug Plans easier to compare than ever, but the information can be still confusing. If you’re still feeling uneasy about which plan is best for you, Plan Advisors can help! Our advisors are knowledgeable of your local Medicare market and can provide comprehensive resources and advice so you’re confident in your plan choice.
Once you’ve decided you’re ready to enroll in a Medicare Part D plan or make changes to your existing plan, it still may not be as easy as simply applying. Like all Medicare plans, you can only enroll or make changes during certain periods throughout the year. It’s important that you are familiar with all of the enrollment periods for Medicare Part D to ensure you don’t have a gap in coverage.
Your first chance to sign up for Medicare Part D Prescription Drug coverage is called the Initial Enrollment Period (IEP). The Initial Enrollment Period begins 3 months before the month you turn 65 and ends 3 months after the month you turn 65.
If you are enrolling in Medicare under the age of 65 because of a qualifying disability you will have a similar Initial Enrollment Period; however, the period will begin 3 months before your 25th month of receiving Social Security or Railroad Retirement Board benefits and end 3 months after. Even if you enroll in the 3 months prior to the 25th month, you will not receive benefits until then.
Did you pass up on enrolling in a Medicare Part D Prescription Drug plan when you turned 65 or do you dislike the plan you’re currently in?
Don’t worry, you have an opportunity to enroll and make changes during the Medicare Annual Enrollment Period (AEP). The Annual Enrollment Period is open from October 15 to December 7 every year, with plans going into effect on January 1 of the following year. The Annual Enrollment Period is also when you can drop Medicare Prescription Drug coverage entirely.
If you missed the opportunity to enroll during either your IEP or AEP, you may still be able to enroll or make a change. There are a variety of circumstances that can allow you to become eligible for a Special Enrollment Periods (SEP).
In addition to qualifying for a Special Enrollment Period, you must also meet all other applicable Medicare Part D eligibility criteria. Each Special Enrollment Period has different rules regarding when changes can be made and the type of changes available. Notifying your plan as far in advance as possible can help increase the amount of time you have to make changes.
Some common circumstances that may qualify for a Special Enrollment Period include:
There are numerous special situations that can qualify for a Special Enrollment Period.
Plan Advisors can help make sure you understand the correct guidelines to avoid delays or discontinuation of your coverage during each of these enrollment periods. Reach out to an advisor today to determine what enrollment dates you need to get on your calendar.