Things to Ask Yourself about Medicare Part D Coverage

November 11, 2016

Medicare Prescription Drug Plans (Part D) offer prescription drug coverage to Medicare beneficiaries.  All people having Original Medicare Part B coverage can opt to enroll in the Part D Plan.  But if you are enrolled with a Medicare Advantage Plan (Part C) that offers prescription drug coverage, you do not have to enroll in Part D.

If you have Part D, here are a few things that will help you understand the Plan better:

  • Your Plan D sends you two documents each Fall: The Evidence of Coverage gives details about the Plan, its benefits, costs, service areas, and networks. The Annual Notice of Change explains changes to benefits, costs or services that will be brought into effect from the beginning of the following year.  These documents can serve as your guide to understanding Part D.
  • Part D may make changes to the list of covered drugs each year. You will need to find out if the drugs you need will be covered in the coming year.  The list of covered drugs can be found in your Plan’s Evidence of Coverage.  You can also visit the Plan’s website or call customer care to get the drug list.  Once you know which drugs are not covered, you may want to talk to your doctor about alternatives that are covered by Medicare.  If this doesn’t work, you may want to consider changing your Plan in the Open Enrollment Period (October 15 – December 7).
  • Most Part D Plans share the cost of your drugs with you through co-payments and co-insurance. Some will also have a deductible that you have to pay before the Plan starts sharing your cost.
  • Plans may change their cost-sharing terms each year. You should be able to find these changes in the Annual Notice of Change.
  • Your drug costs could also change if a drug you take is moved to a different level in a tiered formulary. Tier placement determines what Plan members pay. If this cost goes up, talk to your doctor to consider alternate drugs covered by the Plan, otherwise explore other Plan choices.
  • Your Plan may also change its pharmacy network. You save money on using a network pharmacy, so make sure you examine your Annual Notice and the participating pharmacies carefully.
  • Some Part D Plans restrict the use of certain drugs. These restrictions may be for high cost, or addictive drugs.  If you have a chronic condition, you should look at the Plan’s coverage rules (https://www.medicare.gov/part-d/coverage/rules/drug-plan-coverage-rules.html) to see if the drugs you take are affected.  For restricted drugs:
    • Prior authorization from the Plan may be required to get the drug.
    • You may have to try alternate drugs for treatment before getting approval for the restricted drug.
    • Only a limited amount of the restricted drug may be covered.

Details of the Plan and Plan changes can be found in the Evidence of Coverage, and Annual Notice of Change.  In case of doubts, contact Medicare at 1-800-MEDICARE for customer care.

Source: Medicare.gov

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