What Is Extra Help And Who Is Eligible
You may be eligible for lower premiums, deductibles and coinsurance through Medicares Extra Help program. In 2022, those enrolled in the program pay $3.95 for each generic and $9.85 for each brand name drug.
In 2022, you may qualify if your income is up to $19,320 for an individual and $26,130 for a couple and you have a limited amount of resources such as savings, stocks and bonds. If your income or resources change, you can apply for Extra Help at any time.14
What Is Catastrophic Coverage
Catastrophic coverage is the final coverage phase of a Part D plan. Youll reach your catastrophic coverage only after youve met your regular deductible and paid your way out of the Part D coverage gap. Heres how it works:
- Part D deductible: All Part D plans can have a different deductible, but they do not exceed $480 in 2022. Once youve met this amount, Part D will begin to pay a portion of your medication costs.
- Part D Coverage Gap: also called the Part D donut hole, this is a period that opens after you and your plan have spent a predetermined amount on prescription drugs . During this time, you will pay 25% of the approved costs for your generic medications, and Medicare will pay 75%. For name-brand drugs, youll generally pay 25% of approved costs, but using the drugs full price can get you out of the coverage gap.
- Catastrophic coverage: Once your out-of-pocket costs have reached the yearly limit , youll leave the coverage gap and enter the final coverage stage. Catastrophic coverage offers the same coverage as the other levels, but youll pay reduced out-of-pocket coinsurance and copays.
What extra benefits and savings do you qualify for?
Medicare Part B Premium
Medicare Part B covers physician services, outpatient hospital services, some home health services, durable medical equipment, and some other medical and health services that Medicare Part A does not cover.
Medical insurance premiums, deductions, and co-insurance are adjusted every year in accordance with the Social Security Law. For 2021, the monthly Medicare Part B and annual deductible premiums are higher than the 2020 amounts. The standard monthly premium for Medicare Part B enrollments will be $ 148.50 for 2021, an increase of $ 3.90 from $ 144.60 in the year 2020. The annual deductible amount for all Medicare Part B beneficiaries is $ 203 in 2021, an increase of $ 5 over the annual deductible of $ 198 in 2020.
The Part B premiums and the deductible reflect the provisions of the Continuing Appropriations Act 2021 and the Other Extensions Act .
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Choose The Right Prescription Drug Plan For You
Here are some tips for finding a plan that meets your budget, needs and preferences.17
- Check the prices. The monthly premium is an important consideration but look too at cost-sharing, such as deductibles, coinsurance and copays. A low premium may cost you more in the long run.
- If you prefer one-stop shopping and are willing to choose a plan that limits you to a network of providers, you may have lower premium costs with a Medicare Advantage plan with prescription drug coverage.
- If you take no or very few medications, you may want to opt for a low-premium plan. It will still cover most of the drugs that people on Medicare need.
- If you are taking specific long-term medications, check their availability and costs in various plans. If the drugs you take are generics, look for plans that charge you little or nothing for these.
- If you expect large medication expenses, it may pay to look for a plan that extends additional coverage if you reach high spending levels.
- When selecting a plan, check to see if they have a convenient preferred pharmacy, where you can often get added savings on prescription drugs.
Change Your Medicare Part D Coverage
If your request for a formulary exception is denied, you may want to switch to a different Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan. Of course, before you switch plans, make sure the new Medicare plan covers the medications you need by checking the plans formulary.
You can switch Medicare plans and make changes to your coverage during the Annual Election Period , which runs from October 15 to December 7 each year. During this period, you can:
- Enroll in a Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan for the first time.
- Switch from one Medicare Part D Prescription Drug Plan to another.
- Disenroll from your Medicare Part D Prescription Drug Plan.
- Switch from one Medicare Advantage Prescription Drug plan to another.
- Disenroll from your Medicare Advantage Prescription Drug plan and go back to Original Medicare. You can then add on a stand-alone Medicare Part D Prescription Drug Plan.
If you use the Medicare Advantage Open Enrollment Period to leave your Medicare Advantage plan and return to Original Medicare, you can also use this period to enroll in a stand-alone Medicare Prescription Drug Plan. You also can use this period to switch from one Medicare Advantage plan to another.
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What If I Have A Medicare Advantage Plan
Medicare Advantage plans also known as Medicare Part C are plans that combine Medicare Parts A, B, and usually D. They are administered by private health insurance companies and often come with extras such as dental and vision benefits or gym memberships. But unlike original Medicare, Medicare Advantage plans typically require members to use limited networks of doctors and hospitals. A variety of different Medicare Advantage plans are on the market.
Medicare Advantage plans must cover everything that original Medicare covers, but they may have different rules. Check with your plan about rules, costs and restrictions. You may still have to pay your monthly Part B premium if you have a Medicare Advantage plan, in addition to your monthly MA premium, depending on your plan rules.
How Does Medicare Prescription Drug Coverage Work
Medicare prescription drug coverage is an optional benefit. Medicare drug coverage is offered to everyone with Medicare. Even if you dont use prescription drugs now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when youre first eligible, and you dont have other creditable prescription drug coverage or get Extra Help, youll likely pay a late enrollment penalty if you join a plan later. Generally, youll pay this penalty for as long as you have Medicare prescription drug coverage. To get Medicare prescription drug coverage, you must join a plan approved by Medicare that offers Medicare drug coverage. Each plan can vary in cost and specific drugs covered.
There are two ways to get Medicare prescription drug coverage:
- Medicare Prescription Drug Plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service plans, and Medicare Medical Savings Account plans. You must have Part A and/or Part B to join a Medicare Prescription Drug Plan.
- Medicare Advantage Plans or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A, Part B, and prescription drug coverage , through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called MA-PDs. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.
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Understanding Medicare Part D Prescription Drug Coverage
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ON SCREEN TEXT: What is a Medicare Part D Plan?
The character and speech bubble separate and exit the screen on opposite sides. Blue text appears above a sheet of paper.
ON SCREEN TEXT: Medicare Part D plans are…
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ON SCREEN TEXT: Stand-alone plans that provide prescription drug coverage.
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ON SCREEN TEXT: Part D plans cover certain common types of drugs as regulated by the federal government, but each plan may choose which specific drugs it covers.
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ON SCREEN TEXT: The list of drugs a plan covers is called a formulary.
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ON SCREEN TEXT: Part D plans do not cover:
ON SCREEN TEXT: Drugs that aren’t on the plan’s formulary
ON SCREEN TEXT: Drugs that are covered under Medicare Part A or Part B
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ON SCREEN TEXT: Drugs that are excluded by Medicare
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ON SCREEN TEXT: Medicare Made Clear® by UnitedHealthcare
Your Medicare Plan Doesn’t Cover Prescription Drug Costs Here’s What You Can Do
Nearly 70 percent of American adults between the ages of 40 and 79 use at least one prescription drug, and more than 22 percent use at least five, according to the Centers for Disease Control and Prevention. Under Original Medicare , prescription drug coverage is restricted to a limited number of outpatient drugs, such as those that have to be professionally injected or infused. That means millions of American seniors have to find other ways to cover their medication costs. We outline three of them below.
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When Can I Join Switch Or Drop A Medicare Drug Plan
- When you first become eligible for Medicare, you can join during your Initial Enrollment Period.
- 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 through June 30 and your coverage will start on July 1.
- You can join, switch, or drop a Medicare drug plan between October 15 through December 7 each year and your changes will take effect on January 1 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 join, switch, or drop a plan during the Medicare Advantage Open Enrollment Period between January 1 through March 31 each year.
- If you qualify for a Special Enrollment Period.
Compare Medicare Part D Plans
Are you looking for prescription drug coverage? Medicare.org offers free, accurate comparisons for Medicare Prescription Drug Plans and Medicare Advantage Plans , including Medicare Advantage Prescription Drug Plans . We can also help you find Medicare Supplement coverage to help pay for the out-of-pocket costs that Original Medicare doesnt cover.
Contact a Medicare.org licensed sales agent at TTY 711 to help you find the right Medicare coverage for your needs.
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How Much Does Medicare Part B Cost
The standard Medicare Part B premium for 2022 is $158.50, but this premium may increase if your income falls above a certain level. The Social Security Administration uses the income reported on your most recent federal tax return to determine whether you will be responsible for paying any additional premium during your enrollment. Premiums may increase depending on income, however, there are no income limits to being able to receive Medicare benefits.
What Does Medicare Drug Insurance Cover
Policies vary by which medications they cover, and how much you must pay. But even the least expensive prescription drug plans must cover most of the generic and brand name drugs and the insulin preparations that are generally needed by people on Medicare. And, it must cover all or most of the drugs in the following categories:
- Anticonvulsive treatments for seizure disorders,
- HIV/AIDS treatments,
- Immunosuppressant medications,5and
- Opium Treatment Programs and at least one naloxone product for $0 copay or low-cost sharing.6
Part D plans must also cover vaccines, including shingles shots, which are not covered by Medicare Part B. In 2022, the Medicare Part D insulin savings program provides insulin medication for a $35 maximum copayment.
What does Medicare drug insurance not cover?
In general, Part D plans are not allowed to cover medications for:
- over-the-counter drugs
- sexual or erectile dysfunction
- vitamins and minerals, except for prenatal vitamins, niacin , and fluoride
Plans with enhanced alternative coverage may include some of the drugs on the above list.7
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Medicare Part B Drugs: Cost Implications For Beneficiaries In Traditional Medicare And Medicare Advantage
In the face of rising prescription drug costs, a large majority of the public supports federal efforts to lower drug spending. In his 2022 State of the Union address, President Biden urged Congress to pass legislation to rein in drug costs. In November 2021, the House of Representatives passed the Build Back Better Act , which includes several provisions that would lower prescription drug costs, but the Senate has yet to take action on this legislation. Proposals included in the BBBA would allow the federal government to negotiate the price of some drugs covered under Medicare Part B and Part D require drug companies to pay rebates to the federal government when annual increases in drug prices for Medicare and private insurance exceed the rate of inflation cap monthly insulin costs for people with Medicare and private insurance and cap Medicare beneficiaries out-of-pocket drug spending under Part D .
In the first part of this analysis, we examine Medicare claims data for 2019 to assess cost-sharing liability for Part B drugs for beneficiaries in traditional Medicare . In the second part of our analysis, we use Medicare Advantage benefit design data for 2022 to examine the range in cost-sharing amounts at or below 20% coinsurance charged by Medicare Advantage plans for in-network Part B drugs. We also analyze variation in cost-sharing amounts for out-of-network Part B drugs charged by plans that provide out-of-network coverage.
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What Medicare Part D Plans Cover
Medicare drug plans cover both generic and brand-name drugs. All plans cover certain categories of drugs to treat specific conditions. Each plan decides which specific drugs to insure per category.
Each Medicare Part D plan lists the drugs it covers in a formulary, which typically includes both brand-name and generic drugs. Formularies change, so its very important to check regularly that your medicines are included.
You should also check each plan for restrictions on drug coverage, such as requirements that certain drugs be approved in advance by the insurer.
If you or your provider believe none of the covered drugs will treat your condition adequately, you can apply for an exception.
Where To Get Vaccinated
You have a choice on where to get vaccinated.
In your doctors office: You can get vaccinated in your doctors office. If the office is set up to bill Part D directly for your vaccination, you may only have to pay a copay at the time of your shingles shot. If not, you may have to pay all costs upfront and submit a claim to your Part D plan for reimbursement.
At your local pharmacy: You can go to your local pharmacy to get your shingles shot as long as they offer the vaccine and appropriately trained staff members administer it. The rules for pharmacy vaccination vary by state. You will likely need to pay for the vaccination upfront. Pharmacies are not legally required to dispense medications without payment.
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When You First Sign Up For Medicare
When you first become eligible for Medicare at age 65, you have a 7-month Initial Enrollment Period to apply for Part B. Your eligibility for enrollment starts three months before the month you turn 65. It includes the month of your 65th birthday and the three months following your birth month.
If you sign up for Part B after your 7-month enrollment period, youll be charged a monthly late penalty of 10% for each 12-month period you could have had Part B. The longer you go without Part B, the higher the penalty. However, you will not pay the penalty if you meet certain special enrollment period requirements.
Does Medicare Part B Cover Chemotherapy Drugs
Medicare Part B covers several chemotherapy drugs that are administered through the vein in an outpatient setting.
Part B coverage includes certain oral and intravenous drugs along with anti-nausea drugs to offset the symptoms of chemotherapy. In fact, chemotherapy and other cancer-treating drugs account for the majority of units of Medicare-covered drugs that are thrown away or otherwise discarded by health care providers.
Chemotherapy drugs can be expensive, which is why Part B may not cover all of them. Further coverage for chemotherapy drugs can be found in Medicare Part D or Medicare Advantage plans that include prescription drug coverage.
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