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Prescription Drug Plans

Medicare Part D, the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan (for those enrolled in Original Medicare) or as a set of benefits included with your Medicare Advantage Plan.Unless you have creditable drug coverage and have a Special Enrollment Period, you should enroll in Part D when you first get Medicare. If you delay enrollment, you may face gaps in coverage and enrollment penalties.Each Part D Plan has a list of covered drugs, called its formulary. If your drug is not on the formulary, you may have to request an exception, pay out of pocket, or file an appeal.A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D Plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
  • HIV/AIDS treatments
  • Antidepressants
  • Antipsychotic medications
  • Anticonvulsive treatments for seizure disorders
  • Immunosuppressant drugs
  • Anticancer drugs (unless covered by Part B)
  • Part D plans must also cover most vaccines, except for vaccines covered by Part B.
Part D Plans must also cover most vaccines, except for vaccines covered by Part B.
Some drugs are explicitly excluded from Medicare coverage by law, including drugs used to treat weight loss or gain, and over-the-counter drugs.

Things to consider:

  • If you do not join a Medicare drug plan when first eligible and you don’t have other creditable prescription drug coverage (such as a creditable employer-sponsored plan) you may have to pay a late penalty once you do join.
  • There is a premium for each plan offered. While these premiums may be in some cases quite low – it is important to focus on the TOTAL ANNUAL ESTIMATED COSTS of your medications under each plan. Part D plans not only have a premium, they also can come with deductibles as well as YOUR out-of-pocket costs for the medications you are taking.
  • On top of your Part B premium you may be subject to paying extra. This extra amount is directly related to your income (2 years prior). If your adjusted gross income filing individually is above $97,000 or jointly at $194,000 you will be subject to an extra monthly amount that you will pay. This a confusing step and we take time with our clients to review these costs one on one.
  • Your costs of each drug depend on the carrier and their corresponding plan. Medications under each plan are put into Tiers. The higher the tier – the higher price you will pay for your drugs. Not all drugs for each plan will be in the same Tier which means it is extremely important to pay close attention to how each plan breaks down your list of medications. This is an extremely personal step in determining your drug coverage. We stress the importance of this step with our clients – walking them through these costs so there are no surprises.
  • There are four levels of costs. Deductible, Initial, Coverage Gap or Donut Hole (Drugs get really expensive during this phase), and Catastrophic coverage.  You reach the Coverage Gap when you and the insurance company have paid around $4,660. At this point, you will be paying 25% for brand-name drugs and 75% for generic drugs in 2023.  After your total out-of-pocket drug spending reaches $7,400, you reach Catastrophic Coverage. During catastrophic coverage, you pay either a 5% coinsurance for covered drugs or a co-pay of $4.15 for generic covered drugs or $10.35 for covered brand name drugs, whichever is greater!
  • Plan costs change every year – it is important to review your Part D Prescription Drug plan each year during the Annual Election Period/ Open Enrollment (Oct 15th – December 7th) – we review this with our current clients!

How can we help you?

Part D can end up being an incredibly costly piece of your HealthCare. We give you peace of mind that the plans you are considering are the most comprehensive, for your specific medications, at the lowest annual cost! Examples of what we might do for you are:

  • Understanding creditable drug coverage
  • Doing a comprehensive analysis of your current medications to assist you in choosing the right Part D Plan
  • Reviewing your current medications annually to assist in you deciding to stay or switch plans
  • Assisting in the drug substitution approval process
  • Determining your Income Related Monthly Adjustment amount (IRMAA) – the extra amount you may have to pay

We are contacted/certified with most insurance carriers to represent their Prescription Drug plans. This means we can offer you are broad look at all available plans in your area to ensure you are getting the right plan for YOU.

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