Participation in a Part D prescription drug plan is available to nearly anyone enrolled in Medicare A and B, but it is not mandatory. It can be a good idea to enroll in a Part D plan if:
• You regularly take prescription drugs;
• You do not already have creditable prescription drug coverage elsewhere;
• Your health/family history leads you to believe you will need to take prescription drug in the future;
• You are having difficulty affording your prescription drugs.
HOW AND WHEN TO ENROLL
Initial Enrollment Period (IEP)
The 7-month period that begins 3 months before you turn age 65, includes your birthday month, and ends 3 months after the month you turn age 65.
For those under age 65 with a qualifying disability and receiving Social Security or Railroad Retirement Board disability benefit, you will have a 7-month enrollment period. This period begins 3 months before your 25th month of receiving Social Security or Railroad Retirement Board disability benefit includes your 25th month, and ends 3 months after.
Annual Election/Enrollment Period (AEP)
Begins October 15 and ends December 7 with coverage taking effect January 1st of the coming year.
Special Enrollment Period (SEP)
Allows you to switch or drop a Part D plan under special circumstances. Here are some examples:
1. You returned from living outside the United States after a long-term permanent residence outside the U.S.
2. You are leaving, losing or joining an employer or union.
3. Your plan's contract with Medicare is terminating.
4. You recently involuntarily lost your creditable prescription drug plan.
5. You live in, are moving into, or recently moved out of a nursing home or long-term care facility..Go to Medicare.gov for more information.
What you should know about Part D: Prescription drug coverage...
Even though Part D plans are offered by private companies and can vary, Medicare monitors and regulares how the plans work. There are 4 stages to a Part D drug plan:
1. Annual deductible
Each year, you may be required to meet a Medicare Part D deductible, though some plans may only require a partial deductible or have a zero deductible. During the deductible phase, you will pay the discounted network price for your medications until you meet your plan’s deductible. In 2021, the deductible can be no more than $445.
2. Initial coverageAfter you’ve met your annual deductible amount tallied by your insurer, you move into initial coverage and must pay a copay for your prescription drugs based on the plan’s drug formulary. The formularies can be different from plan to plan. Under the formularies, medications are separated into Tiers. Each Tier has a copay amount for the drugs in that tier. For example, drugs in Tier 1 may have a $5 copay for generic medications, while Tier 3 has a $40 copay and represents certain brand name drugs. The insurer will continue to keep track of your spending until you and the insurance company reach the out-of-pocket limit set by Medicare for the year you are in. In 2021, the out-of-pocket limit for the initial coverage phase is $4,130.
3. Coverage gapAfter reaching your initial coverage limit for the year, you enter what is referred to as the coverage gap. During this time, you pay no more than 25% of the cost of your medication. The insurer will be keeping track of your spending until you reach the coverage gap out-of-pocket limit set by Medicare for the year you are in. In 2021, the out-of-pocket limit for the coverage gap phase is $6,550.
4. Catastrophic coverageAt the end of the coverage gap, you will get catastrophic coverage, for which you pay a small coinsurance amount or copayment for covered drugs for the remainder of the year.
Drug utilization rules
Insurers are allowed to set certain rules to ensure safety and manage costs. Here are some common examples:
Quantity limits are set to control how much medication you can purchase at once or upon each refill. If you doctor prescribes outside of these limits, they will be required to file an exception form.
Prior authorization stipulates that your doctor must obtain approval from the plan before allowing a pharmacy to dispense certain medications.
Step therapy regulates prescribing more expensive drugs when less expensive alternative may be as effective. You may be required to try similar, lower cost drugs before the plan will cover the prescribed drug. If the alternative works, both you and the insurer save money.
Prescription drug plans vary widely enough so if you have questions, we urge you to contact myHealthPolicy at (888) 928-1465
A licensed insurance agent will speak with you about your situation to help you determine what plan features will fit your prescription drug needs. Rest assured, we take your confidentiality and your security seriously. Our goal will be to help you determine the type of plan that fits you financially and personally.
If you still have questions, it may be helpful to speak with one of our local, licensed insurance agents who have access to information about the companies, plans, networks in your area.