In 2003 the federal government enacted the Prescription Drug Improvement and Modernization Act, which started in 2006 -so Medicare recipients could benefit from federal subsidies, lowering prescription drug costs.
- Anyone enrolled in Medicare, Part A and/or Medicare Part B, is eligible for coverage -regardless of health status, income, or resources.
The program is voluntary and helps anyone on Medicare reduce Part D drug costs. Medicare prescription drug plans are only offered by Medicare approved private companies.
- If you’re enrolled in Original Medicare, you ought to consider prescription drug coverage, in order to lower out-of-pocket costs of both generic and brand-name drugs.
Anyone’s health can turn on a dime. So, it’s important to join one of these plans whenever you’re first eligible -or, you may be assessed a late enrollment penalty you won’t want to pay.
- In addition, you may have to wait until Medicare Annual Election Period to enroll.
- if you missed your Initial Enrollment Period, coverage starts the following January 1st.
Key Medicare Part D Benefits:
The Medicare Prescription Drug program includes plans that offer various types of coverage. In addition, some Medicare beneficiaries may qualify for Extra Help with their Medicare prescription drug plan costs.
- To qualify for the Extra Help program, you must be enrolled in Medicare, have limited income and/or resources, and reside in one of the 50 United States, or the District of Columbia.
To get Extra Help with Medicare prescription drug plan costs, if you don’t automatically qualify, it’s important to complete and submit an application to the Social Security Administration (SSA).
- The process is simple and fast.
- They’ll usually mail your determination letter, in about two-weeks.
- Even if your income and/or resources are more than amounts listed online, it’s important to apply:
- Because, the aggregate amounts may change any given time.
Note: According to Medicare guidelines -doctor samples, discount cards, free clinics, or discount websites aren’t considered creditable prescription drug coverage options.
Original Medicare Part B provides limited drug coverage: for injections you get in a doctor’s office, certain oral cancer drugs, and drugs used with some types of durable medical equipment -such as a nebulizer or external infusion pump.
- Under limited circumstances Part B may cover certain drugs you get in hospital outpatient settings.
- You’ll be responsible to pay 20% of Medicare approved amounts for these drugs, and the Medicare annual Part B deductible is applicable.
- Generally, self-administered drugs received in emergency rooms, observation units, surgery centers, or pain clinics aren’t covered by Medicare Parts A or B.
- Your Medicare drug plan (Part D) may cover these drugs under certain circumstances -but, you’ll likely have to pay out-of-pocket for these drugs – And send the bill to your drug plan for a refund.
You can join or switch Medicare Part D drug plans during Medicare Annual Election Period, from October 15th through December 7th each fall.
- Coverage begins January 1st the following year.
Each Medicare drug plan has different coverage and costs, but all plans must offer at least a standard level of coverage set by Medicare.
- Your copays are affected by which drugs you use, which plan you join, and whether you buy prescriptions locally or through the plans mail order service.
- More important to you, if you get Extra Help paying for prescription drugs -you’ll enjoy enhanced benefit levels.
Out-of-pocket costs are affected by:
- Monthly premium
- Copayments or coinsurance
- The coverage gap (called the “donut hole”)
- Catastrophic coverage
- And, your level of Extra Help -if applicable
Note: A small group, fewer than 5% of all folks on Medicare, may pay a higher monthly premium -based on their income.
If you don’t pay your entire Part D premium (including the extra amounts) you may be disenrolled from your Medicare drug plan.
Drug lists (Formularies)
Each Medicare drug plan has its own unique list of covered drugs
called a formulary.
Medicare drug plans aren’t required to cover certain drugs, like benzodiazepines, barbiturates, drugs for weight loss or gain, and erectile dysfunction drugs.
- Some plans may cover these drugs as an added benefit.
- Also, Medicare drug plans generally don’t pay for over-the-counter drugs.
- To ensure people with different medical conditions are able to get prescriptions they need, drug lists for each plan must include a range of drugs in each prescribing category.
- All Medicare drug plans must have at least two drugs per drug category.
- But, each plan can choose which specific drugs they’ll cover.
- Plans must cover almost all drugs within protected classes.
- Such as antipsychotics, antidepressants, anticonvulsants, immunosuppressants, cancer, and HIV/AIDS drugs.
Every Medicare Prescription Drug Plan negotiates with drug companies’ to get lower prices for drugs on their lists. So, joining one of these Part D plans will save you money.
- More importantly, using generics instead of brands will save even more.
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