Part D - Prescription Drugs

When you can enroll:  

• Your initial enrollment period, when you first become eligible for Medicare.
• If you get Part B for the first time during the general enrollment period, you can also join a Medicare drug plan from April 1-June 30. Your coverage will start on July 1.
• You can join, switch or drop between October 15- December 7 each year. Your changes will take effect on January of the following year, as long as the plan gets your request before December 7.
• If you’re enrolled in a Medicare Advantage Plan you can switch or drop a plan during the Medicare Advantage Open Enrollment Period, between January 1- March 31 each year.
• Special Enrollment Periods – if you qualify. (see below)

Late enrollment penalty:  

• This amount is added permanently to your Part D premium. You may owe this penalty if your Initial Enrollment Period is over and you have not had Part D or other creditable prescription drug coverage for 63 days or longer
• If you get Extra Help you do not pay this penalty.

Take these steps to avoid a penalty:  

• Join Part D when you’re first eligible.
• Enroll in Part D if you lose your other creditable drug coverage.
• Keep records showing when you have other drug coverage, and tell your plan if they ask about it.
• The penalty amount is 33.19 for every year you do not enroll. The penalty increases slightly every year.
• If you disagree with your penalty, you can request a review or reconsideration. Generally you need to submit your request within 60 days of your first letter received indicating you need to pay a penalty.

Special Enrollment Periods: When you can switch, join, or drop your Medicare drug coverage plans if you meet certain requirements listed below, otherwise you are generally required to stay with your plan for an entire year. You may qualify for special enrollment if you…  

• Move out of your plans service area
• Lose other creditable prescription drug coverage’s
• Getting transferred or living in a institution such as a nursing home.
• Have (or lose) Medicaid
• Qualify for Extra Help

5 Star Special Enrollment Period:  

• If a Medicare Prescription Drug Plan has 5 stars for its overall rating, you can enroll from Dec. 8, 2018- Nov. 30, 2019. You can only do this once during this time frame if you choose to use this option for your Prescription Drug Plan.
• Special Note: If you have a Medicare Advantage Plan and it includes prescription drug coverage, you’ll be dis-enrolled from your Medicare Advantage Plan. If this occurs you’ll be returned to Original Medicare coverage.

Your costs will vary depending on:  

• Your prescription and whether they’re on your plan’s formulary (list of covered drugs) and depending on what “tier” the drug is included in.
• Which phase of your drug benefit you are in. For example, if you have met your deductible or not.
• The plan you choose, and the costs for these plans vary each year.
• Which pharmacy you use. Your out of pocket may be less at a preferred pharmacy because it has agreed to charge less with your provider.
• Whether you receive Extra Help.

Monthly Premium:  

• These plans have a monthly premium. You will pay this in addition to your part B premium. If you get your coverage through Medicare Advantage Plan your monthly premium may include a cost for prescription drug coverage.
• You do have the option to contact your drug plan if you want your premium deducted from your monthly social security or Railroad Retirement Board payment. You also contact your drug plan if you want to stop deducting your payment from your benefits.
• If you have a higher income ($85,000 if single, $170,000 if married & file jointly) you will pay more.
• Usually this premium will be deducted from your social security or your benefits from the Railroad Retirement Board. If you’re not taking social security payments monthly premiums can be deducted through Electronic funds transfer or billed directly to your home. If you fail to do this you may lose your Part D coverage.
• If you have any questions or concerns please call us and we’ll gladly help you sort it out.

Yearly Deductible: This is the amount you need to pay before your drug plan begins to pay its share of your covered drugs, however some plans do not have deductibles. Co-payments/Coinsurance  

• These are the amounts you pay for your covered prescriptions after the deductible has been met. You pay your portion and your insurance pays its part as well. These amounts may vary throughout the year due to coinsurance & variance in the drugs cost.

Coverage Gap:  

• Most Medicare drug plans have a coverage gap which occurs after you and your drug plan together have a spent $3820 for covered drugs. In 2019, once you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 37% of the plans cost for covered generic drugs until you reach the end of the coverage gap. Not everyone will enter the coverage gap because their drug cost won’t be high enough.
• These costs all count toward you getting out of the coverage gap:
• Your yearly deductible, coinsurance, and co-payments
• What you pay in the coverage gap – once you spend $5100 on covered drugs you will reach the end of the coverage gap.
• The drug plan premium and what you pay for drugs that aren’t covered don’t count toward getting you out of the coverage gap.
• Some plans offer additional cost sharing reduction in the gap beyond the standard benefits and discounts on brand name and generic drugs, but they may charge a higher monthly premium. Check with the plan first to see if your drugs would have additional cost sharing reduction while you’re in the gap.

Catastrophic Coverage  

• Once you’ve surpassed the initial coverage of $3820 of initial drug coverage, and you’ve met the out of pocket costs of the coverage gap – $5100 – you automatically get catastrophic coverage.
• In catastrophic coverage you only pay a reduced coinsurance or co-pay for covered drugs for the rest of the year.
• Note: If you get Extra Help, you won’t have some of these costs.

Your plan will provide you with a list of covered drugs:  

• Many place these drugs into tiers, and costs vary by the tiers the drugs are in.
• You can ask for exceptions in certain situations if your drug is in a higher (more expensive) tier.

Plans may have one of these three coverage rules:  

• Prior Authorization: You and your prescriber must contact the drug plan before you can fill certain prescriptions. You may need to prove the drug is medically necessary before it will be covered.
• Quantity Limits: Your plan may place a limit on how much you can get of any one drug within a certain time period.
• Step therapy: This is where your plan insists you try less expensive drugs before covering the more expensive options.

If you get your prescriptions auto-refilled in the mail:  

• You should approve these before they are sent. If you get a prescription you don’t want, you may be eligible for a refund.

Medication Therapy Management (MTM) Program:  

• This a program designed to help you understand your prescriptions. Medicare Prescription Drug Plans are required to offer these to members who meet certain requirements. The services included are free and usually include a discussion with a pharmacist or health care provider.
• Please call us if you feel this is something you feel you need. It’s very important you take your prescriptions correctly.

Your Part D coverage will most likely not work with other types of insurance coverage. Please contact our office you want to learn if Part D will work well with your current insurance coverage!