PART D
PRESCRIPTION DRUG COVERAGE
Currently we are offering Medicare Part D consultations for both Medicare Supplement clients and non-clients. To do so, we are required to collect a signed SCOPE of appointment 48-hours ahead of time. The SCOPE of appointment simply details what our meeting will cover. It is required by Medicare. All phone calls on Part D and Medicare Advantage are recorded.
It is important that all Part D members review the upcoming year’s changes during the Annual Enrollment Period. After this time, there may not be opportunity to change plans during the year.
Part D Prescription Drug Coverage
Medicare Part D is a voluntary program that covers outpatient prescription drugs. You are not required to have a Part D plan, but if you do not enroll into a plan when you are first eligible you may have to pay a lifetime Late Enrollment Penalty if you decide to enroll later on. This coverage is provided through private plans that have a contract with the federal government, and come as standalone prescription plans or bundled with other benefits in a Medicare Advantage plan.
Plan Considerations
Premium: Each Medicare Part D plans requires a monthly premium, if you have an IRMAA surcharge or late enrollment penalty those charges will be in addition to the standard plan premium. If you decide to use a Medicare Advantage plan the premium for your prescription coverage will be included in the total plan premium.
Deductibles, Copays, & CoInsurance: Other costs associated with Part D coverage include deductibles. Not every plan will have a deductible, and if there is a deductible with your plan it may apply to all medications covered or only certain tiers of medications. A deductible is the amount you have to pay before the plan starts sharing the cost. Copayments are fixed costs, while coinsurance is a percentage of the prescription cost. Prescriptions are separated into tiers and each tier is assigned a copay or coinsurance amount.
Coverage Gap & Catastrophic Coverage: Once you and your plan have reach a combined total of $5,030 on covered drugs, you will enter the coverage gap. The coverage gap is also known as the “donut hole.” This is the cost limit in 2024, these amount may change annually. In 2025, the coverage gap will be eliminated. During the coverage gap phase of Part D coverage the enrollee will pay 25% of the drugs cost, for both generic and brand name drugs, and the plan will pay the remaining 75%. If the costs reach a combined total of $8,000 you will enter the catastrophic coverage phase. During the phase the enrollee will pay up to 5% of the drugs cost and the plan and Medicare will pay the rest.
Pharmacy Network: In order to receive the benefits from your plan, you must receive prescriptions from a pharmacy contracted with the plan. Finding a pharmacy in network is rarely an issue. However, the pharmacy you choose may effect the cost of your prescriptions. Some Part D plans contract pharmacies as either “standard’ or “preferred.” Preferred pharmacies will typically have a lower cost in certain tiers, than the same category at a standard pharmacy. Each company offers a mail order pharmacy service which you can utilize to receive a 3 month supply of qualifying medications delivered to your mailbox.
Formulary: Every medication covered by the plan, and what tier it belongs to, can be found in the plan’s formulary. The formulary will vary by insurance company and even between plans offered by the same company. It is important to verify that your prescriptions are covered before making a new plan selection. Prescription Drug plans, like Medicare Advantage plans, have an annual contract. Premiums, copays, coinsurance, deductibles, and formulary is subject to change January 1 of each year.
Utilization & Restrictions: Plans are permitted to impose restrictions on covered drugs to help control costs. Those restrictions include Prior Authorization, Step Therapy, and Quantity Limits. Prior Authorization requires the prescribing physician to “justify’ or explain to the plan why the medicine is medically necessary. If the Prior Authorization is denied an appeal can be filed. A Quantity Limit is when the plan limits a dosage over a specified period, e.g. x miligrams over 30 days has a quantity limit of 60. Step Therapy may require a trial of a different drug that works similarly or confirmation you have tried similar versions of this drug and that it didn’t work for you. If you are having issues with your drug coverage or any of these restrictions it is possible to file an appeal. Call or schedule an appointment so we can help you get the coverage you need!