How Medicare Covers Prescription Drugs

How Medicare Covers Prescription Drugs

David Sayen

Courtesy: Medicare

Did you know that Medicare helps to pay for prescription medications?

Even if you don’t take many prescription medications now, you should consider joining a Medicare drug plan. There are two ways to get Medicare prescription drug coverage:

• Medicare stand-alone drug plans, also known as Part D plans, add drug coverage to Original Medicare, as well as to some Medicare Cost Plans and Medicare Private Fee-for-Service plans. You must have Medicare Part A or Part B to join a stand-alone Part D plan.

• Medicare Advantage plans and other Medicare health plans often include prescription drugs. Medicare Advantage plans are managed care plans, similar to HMOs or PPOs. Many, but not all, Medicare Advantage plans offer prescription coverage. To join such a plan, you must have Medicare Part A and Part B.

• You can sign up for either type of drug plan when you first become eligible for Medicare or during Medicare’s open enrollment season, which runs from Oct. 15 to Dec. 7 each year.

Beware: If your Medicare Advantage plan includes prescription benefits and you join a Part D plan, you will be dis-enrolled from your Medicare Advantage plan and returned to Original Medicare.

How much does a Medicare drug plan cost? It varies, depending on what plan you choose, which drugs it covers, which pharmacy you use and whether you are eligible for the Extra Help program (more on that later).

Most stand-alone, or Part D, plans charge a monthly premium, which you must pay in addition to your Part B premium. If you are in a Medicare Advantage plan, the monthly premium for that plan may include an amount for drug coverage.

Most Medicare drug plans also have a yearly deductible, an amount you must pay before the plan begins paying for its share of your drugs. Once the deductible is met, you will also pay a co-payment or co-insurance amount at the pharmacy counter.

In addition, most Medicare drug plans have a coverage gap, also known as the “donut hole.” The gap begins after you and your drug plan together have spent a certain amount for your drugs. For more details on the gap, see the “Medicare & You” handbook, mailed to every Medicare beneficiary annually and also available online, at https://www.medicare.gov/Pubs/pdf/10050.pdf.

Once you are out of the gap, you get “catastrophic coverage,” which means you only have to pay a co-payment or co-insurance amount for your drugs for the rest of that calendar year.

However, not everyone will enter the coverage gap because his or her drug costs won’t be high enough. The gap is scheduled to be eliminated by 2020.

Keep in mind that not every Medicare drug plan covers every drug. You should check with the plan to make sure that the drugs you need are covered. Also, plans may have restrictions such as prior authorization, quantity limits and step therapy, which require that you try a lower-cost drug before the plan will cover a high-priced medication.

You or your doctor may appeal if you believe that such a rule should be waived.

I also want to mention the Extra Help program, which assists low-income individuals in paying for their prescriptions. If you qualify, Extra Help can save you thousands of dollars annually on your drugs.

For more details, see the “Medicare & You” handbook.

David Sayen is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

David Sayen is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories.

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