Medicare Part D

Medicare started offering insurance coverage for prescription drugs through Medicare Part D Prescription Drug Plans and other health plan options. Medicare’s prescription drug coverage will typically pay over half of your drug costs, for a monthly premium. It will also provide peace of mind because it protects you once your out-of-pocket drug spending is more than $4,850. Even if you don’t use a lot of prescription drugs now, you should consider joining.

Important points you need to know:

  • Medicare prescription drug coverage helps you pay for the prescriptions you need
  • Medicare prescription drug coverage is available to all people with Medicare
  • There is additional help for those who need it most
  • Medicare prescription drug coverage pays for brand name as well as generic drugs

Our Agency can show you the Medicare Part D Plans available in your state.  For a complete list of all Medicare plans, go to www.medicare.gov.

Basic Information

What is Medicare prescription drug coverage?

Who can get Medicare prescription drug coverage?

When can I get Medicare prescription drug coverage?

How does Medicare prescription drug coverage work?

Why should I get Medicare prescription drug coverage?

What if I have a limited income and resources?

Things to Consider

Cost

Coverage

 

What is Medicare prescription drug coverage?
Medicare prescription drug coverage is insurance that covers both brand-name and generic prescription drugs at participating pharmacies in your area. Medicare prescription drug coverage provides protection for people who have very high drug costs or from unexpected prescription drug bills in the future. Drug plans must contract with pharmacies in your area for the most cost effective rates, while some companies offer mail order programs to provide extra convenience. If you need help, let a First Jersey agent explain all of your options in determining what is the most cost-effective and convenient way to have your prescriptions filled

Who can get Medicare prescription drug coverage?
Everyone with Medicare is eligible for this coverage, regardless of income and resources,health status, or current prescription expenses.

When can I get Medicare prescription drug coverage?
You may sign up when you first become eligible for Medicare (three months before the month you turn age 65 until three months after you turn age 65). If you get Medicare due to a disability, you can join from three months before to three months after your 25th month of cash disability payments. If you don’t sign up when you are first eligible, you may pay a penalty. If you didn’t join when you were first eligible, your next opportunity to enroll will be from November 15 to December 31.

How does Medicare prescription drug coverage work?
Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. There are two ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage Plan or other Medicare Health Plan that offers drug coverage.

Whatever plan you choose, Medicare drug coverage will help you by covering brand-name and generic drugs at pharmacies that are convenient for you.

Like other insurance, if you join, generally you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescription, including a copayment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium.

Why should I get Medicare prescription drug coverage?
Medicare prescription drug coverage provides greater peace of mind by protecting you from unexpected drug expenses. Even if you don’t use a lot of prescription drugs now, you should still consider joining. As we age, most people need prescription drugs to stay healthy. For most people, joining now means protection from unexpected prescription drug bills in the future.

What if I have a limited income and resources?
There is extra help for people with limited income and resources. Almost 1 in 3 people with Medicare will qualify for extra help. If you qualify for extra help, Medicare will pay for almost all of your prescription drug costs. You can apply or get more information about the extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.socialsecurity.gov.  A First Agent can also provide information on statewide assistance plans.

Cost

Premium
There is a monthly cost you pay to join a Medicare drug plan. Premiums vary by plan.

Deductible
This is the amount you pay for your prescriptions before your plan starts to share in the costs. Deductibles vary by plans. Some plans may not have any deductible.

Copayment/Coinsurance
This is the amount you pay for your prescriptions after you have paid the deductible. In some plans, you pay the same copayment (a set amount) or coinsurance (a percentage of the cost) for any prescription. In other plans, there might be different levels or “tiers,” with different costs. (For example, you might have to pay less for generic drugs than brand names. Or, some brand names might have a lower copayment than other brand names.) Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.

Coverage

Formulary
A list of drugs that a Medicare drug plan covers is called a formulary. Formularies include generic drugs and brand-name drugs. Most prescription drugs used by people with Medicare will be on a plan’s formulary. The formulary must include at least two drugs in categories and classes of most commonly prescribed drugs to people with Medicare. This makes sure that people with different medical conditions can get the treatment they need.

Prior Authorization
Some drugs are more expensive than others even though some less expensive drugs work just as well. Other drugs may have more side effects, or have restrictions on how long they can be taken. To be sure certain drugs are used correctly and only when truly necessary, plans may require a “prior authorization.” This means before the plan will cover these prescriptions, your doctor must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered. Plans might have other rules like this to ensure that your drug use is effective.

Coverage Gap
If your total drug costs reach $3,310 in 2016*, you enter the Coverage Gap (also called the “Doughnut Hole”). While in the Coverage Gap, you will pay 45% of the cost of brand name drugs and 58% of the cost of generic drugs until the end of the calendar year or until your out-of-pocket costs reach $4,850*.

Catastrophic Coverage
If your total out-of-pocket costs reach $4,850 in 2016*, you enter Part D Catastrophic Coverage.  At this point, you pay $2.95 for generic drugs and $7.40 for brand name drugs OR 5%, whichever is greater.  This coverage lasts until the end of the calendar year.

*All data collected through www.medicare.gov