Whether you’re new to Medicare, or are reviewing your coverage options for 2017 during Medicare’s Annual Election Period (Oct 15 – Dec 7), do you know how to find the best drug plan to meet your needs? The terrain is complicated, so it’s good to review some basics of coverage and tips to find the plan that best suits you. Below is a write up by the Medicare Rights Center, one of the Medicare Minute topics.
Understanding Part D Plan Selection
Point 1: Understand Medicare Part D basics
Coverage: Medicare Part D covers outpatient prescription drugs. Part D is only available through private insurance companies. Each plan has its own list of drugs that the plan covers, called a “formulary.” Some drugs are excluded from Medicare coverage by law, so they cannot be covered by Part D. Some examples are drugs used to treat weight loss or gain, drugs that have not been approved by the Food and Drug Administration (FDA), and prescription vitamins and minerals.
Note: Part D does not cover drugs that are covered by Medicare Parts A and B, such as drugs
you receive as part of inpatient hospital treatment (Part A), chemotherapy drugs (Part B), or
certain vaccines (Part B).
Type of Plan: If you have Original Medicare, you can select a stand-alone Part D plan. If you are in a Medicare Advantage Plan, it most likely includes Part D prescription drug coverage. If it does not, you can select a stand-alone Part D plan.
Costs: Plans have monthly Part D premiums, coinsurances and/or copays, and most have a deductible. For 2017, the maximum annual Part D deductible will be $400 and the average monthly premium will be $35.63.
Restrictions: Some Part D plans place certain restrictions on covered drugs, such as prior authorization, step therapy, and quantity limits. Prior authorization means that you must ask your plan for permission to cover the drug before it will do so. Your prescribing provider can help you get prior authorization. Step therapy means that your plan requires you to try a cheaper version of your drug before it will cover the more expensive one. Quantity limits mean that your plan limits how much of a drug you can get within a certain period of time.
Point 2: Pick a Part D plan that meets your health care needs
Before choosing your Part D coverage, make a list of all of the prescription drugs you take. Include on this list their names (noting correct spelling from your pill bottles or prescriptions), their dosages, and whether they are brand-name or generic. This list will make it easier to find a plan that includes your drugs on its formulary. Next, you should think about costs. Consider questions such as, what are the premiums and deductibles for the different plans that cover the drugs on my list? What are each plan’s coinsurance amounts or copayments for the covered brand-name versus generic drugs? Are my pharmacies within the plan’s network? Does the plan have a mail-order option that it prefers its members use? Lastly, call the plan and ask if there are any restrictions on your covered drugs, such as prior authorization, step therapy, or quantity limits. It may be harder for you to access a covered drug if you do not know about the restrictions before you
go to the pharmacy to fill your prescription.
Point 3: Know how and when to enroll in a Part D plan
Unless you already have good drug coverage through employer insurance or another source, you should sign up for a Part D plan for the first time during your Initial Enrollment Period. Your Initial Enrollment Period begins three months before your 65th birthday, includes the month of your birthday, and ends three months after. If you delay enrollment, you may have a late enrollment penalty added to your monthly premium when you later enroll.
After your initial enrollment, you can change your Part D prescription drug coverage during Medicare’s Open Enrollment Period, which spans October 15 to December 7 each year. If you make a change during open enrollment, your new Part D coverage becomes effective the following January. Why change? Part D plans can change their formularies and costs from year-to-year, which they outline in a document called an Annual Notice of Change. Part D enrollees receive these notices from their plan each September. Review the notice, and if you are unhappy with the plan changes, such as if the plan will no longer cover your drugs, you can use the Medicare Open Enrollment Period to sign up for a different plan.
For objective one-on-one assistance reviewing your 2017 Medicare coverage options, contact your State Health Insurance Assistance Program (SHIP). SHIPs offer in-person and telephone counseling. Their mission is to educate and empower you to make informed health insurance decisions.
You should never be pressured to join a particular plan or be enrolled in a plan without your knowledge or consent. If you suspect an insurance plan or agent of unscrupulous or fraudulent behavior, report the activity to your local Senior Medicare Patrol (SMP). Their mission is to help you prevent, detect, and report health care fraud, errors, and abuse.
- Be prepared for changes that may occur in 2017 by making a list of the prescription drugs you take, reviewing your Annual Notice of Change, and contacting your plan with any questions
- Make sure your plan will still cover your drugs next year, and if not, review other plan options.
- For help reviewing your options, call 1-800-MEDICARE, go to the Medicare Plan Finder at www.medicare.gov, or contact a State Health Insurance Assistance Program (SHIP) counselor.
- If you suspect fraud, contact your Senior Medicare Patrol (SMP).