Friday, November 18, 2022

Does Original Medicare Cover Prescription Drugs

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Drugs That Are Used With Durable Medical Equipment

Does Original Medicare Cover Prescriptions?

Durable medical equipment includes things like walkers, wheelchairs and other supplies used in the home and are covered by Medicare Part B. Durable medical equipment can also include things like nebulizers, infusion pumps and other equipment that pair with medication.

Medicare Part B covers drugs that are infused through durable medical equipment. That can include insulin when the use of an insulin pump is determined to be medically necessary.

Finding A Medicare Advantage Plan With Prescription Drug Coverage

A person can view available Medicare Advantage plans in their area by using Medicares Find a Medicare Plan function. This function allows a person to search by area for available plans that offer prescription drug coverage.

If desired, a person can enter the names, dosages, and quantity of medications they regularly take to see how plans cover these medicines.

A person can sign up for a Medicare Advantage plan that includes a prescription drug plan at the following times:

Initial Enrollment Period: This period starts 3 months before a persons 65th birthday, spans the month they reach 65 years, and finishes 3 months after their birth month.

A person can sign up for Medicare Advantage during this time.

Open Enrollment Period: This spans from . During this window, a person can sign up for a Medicare Advantage plan or switch from one to another.

Medicare Advantage Open Enrollment Period: This annual period runs from and has more limitations on enrollment compared to the fall.

During this time, a person can change from one Medicare Advantage plan to another or drop their Medicare Advantage plan and return to Original Medicare.

Special Enrollment Periods: A person may qualify in special circumstances, such as losing their employers health coverage or moving to an area to which the plans network does not extend.

Original Medicare Does Not Include Prescription Drug Coverage For Self

Generally speaking, Original Medicare, which refers to Parts A and B, does not cover prescription drugs. However, Medicare will usually cover prescription drugs if they are part of a hospital stay, or if they are administered by your healthcare provider.

In addition to this, there is a distinct part of Medicare that specifically covers prescription drugs, and prescription drug coverage is also part of many Medicare Advantage plans. Well take a look at all of the details as well as which options you have.

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What Is Medicare Part D Prescription Drug Coverage

Medicare Part D helps cover the cost of prescription drugs. Part D is optional and only provided through private insurance companies approved by the federal government. However, Part D is offered to everyone who qualifies for Medicare. Costs and coverage may vary from plan to plan.1 Read on to learn more about Medicare Part D prescription drug coverage, how to get it and what it covers.

What Does Medicare Part D Cover

Prescription Drug Coverage

Under Medicare Part D, prescription drug plans are available from private, Medicare-approved insurance companies, so benefits and cost-sharing structures differ from plan to plan. However, the Center for Medicare and Medicaid Services sets minimum coverage guidelines for all Part D plans. These rules require all plans to cover medications to treat most illnesses and diseases.

Each Medicare prescription drug plan uses a formulary, which is a list of medications covered by the plan and your costs for each. Most plans use a tiered copayment system. Prescription drugs in the lowest tiers, usually generic medications, have lower copayments. Brand-name and specialty medications in the higher tiers cost more out-of-pocket.

Medicare Part D only covers prescription drugs that are FDA approved. Experimental medications are generally not covered.

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What Exactly Is Medicare Part B

Medicare Part B covers a wide range of healthcare services that can be broken down into two categories: medically necessary services and preventive services.

  • Medically necessary services. These are services and supplies you need to diagnose and treat your medical condition. Services include doctor visits, ambulance transport, outpatient therapy, and mental health support. Supplies include durable medical equipment such as blood sugar meters, oxygen equipment, and wheelchairs, to name a few.

  • Preventive services. These are services to prevent illness or diagnose illness at an early stage when treatment is most beneficial. Mammograms, colonoscopies, prostate cancer screenings and bone density screenings are some of the preventive services covered in Part B. Another example is immunizations, including the COVID-19 vaccine.

Is Generic Medication Covered By Medicare Part D

All Part D plans use the formulary tier system to cover generic and brand-name medications. Most people prefer Tier 1 generics because the plan and copays are usually the most affordable.

Keep in mind that each plans tier formulary contains different generics, so double-check if it includes your medications. If a medication isnt on the formulary, inquire at your pharmacy about the cost of purchasing it without Part D.

In addition, plans can alter the medications available in their tiers. Before enrolling in a Part D plan, make sure your plan still covers the medications you take every year during annual open enrollment.

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What Does Medicare Prescription Drug Plan Cover

Prescription drug plan coverage can vary by plan. Each plan has a drug formulary that shows prescriptions it will pay for and how much it will pay. Each plan has its own set of deductibles and copays, and each plan has a regional network of pharmacies that will fill prescriptions within your particular plan.

From January 1 To March 31 Each Year

What does Medicare Part D cover?

You can sign up during general enrollment from January 1 to March 31 if:

  • You didnt sign up when you were first eligible.

  • You cancelled Part B without having other insurance but would like to re-enroll.

  • You didnt enroll for Part B within eight months after your employer or union health plan ended or when you stopped working, whichever happened first.

Regardless, if you apply for Part B between January 1 and March 31, your coverage will start on July 1.

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Formulary Tiers: What You Should Know

Many Part D plans will divide their formulary into tiers. These are basically just levels of payment that you will be responsible for when buying certain drugs. For example, drugs that fall into tier one may be cheap generic drugs that you pay nothing or just a small copayment for. Higher tiers may consist of very costly brand-name drugs, and will probably require a higher copayment or coinsurance from you.

The number of tiers that a plan has will vary, so its important to make sure you know which tier the drugs you need will fall under.

Access Public And Private Programs

A number of federal, state, and private programs exist to help people make their prescription drugs more affordable. Medicare recommends consulting the National Patient Advocate Foundation or the National Organization for Rare Disorders for information about programs available to you.

The Social Security Administration also offers the Extra Help program, which assists low-income Medicare beneficiaries with their prescription drug plan fees. You can check eligibility qualifications and apply for Extra Help on the official government SSA website.

You can also check to see whether you qualify for State Pharmaceutical Assistance Programs or Manufacturerâs Pharmaceutical Assistance Programs. To find out what these programs can do for you, visit the official U.S. government website for Medicare.

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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.

Understanding The Donut Hole Coverage Gap

Prescription Drug Coverage for Medicare recipients

For most Medicare prescription plans, there is a temporary limit on what the plan covers. This is called the coverage gap, or the donut hole. In 2022, this coverage gap will be triggered once you and your plan spend a combined $4,430 on covered medications. Once youre in the coverage gap, you will pay a maximum of 25% of the cost for brand-name drugs in your plan. Although you pay only a fraction of the cost of your prescriptions, almost the full price of the drugs count toward your out-of-pocket costs.12

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There Are 2 Ways To Get Medicare Drug Coverage:

1. Medicare drug plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Private FeeforService plans, and Medical Savings Account plans. You must have

and/or

to join a separate Medicare drug plan.

or other

with drug coverage. You get all of your Part A, Part B, and drug coverage, through these plans. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

To join a Medicare drug plan, Medicare Advantage Plan, or other Medicare health plan with drug coverage, you must be a United States citizen or lawfully present in the United States.

Visit Medicare.gov/plan-compare to get specific Medicare drug plan and Medicare Advantage Plan costs, and call the plans youre interested in to get more details. For help comparing plan costs, contact your State Health Insurance Assistance Program .

How To Get Prescription Drug Coverage

Medicare drug coverage helps pay for prescription drugs you need. Even if you dont take prescription drugs now, you should consider getting Medicare drug coverage. Medicare drug coverage is optional and is offered to everyone with Medicare. If you decide not to get it 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 drug coverage. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage. Each plan can vary in cost and specific drugs covered.

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Does Medicare Part C Cover Prescription Drugs

According to the Kaiser Family Foundation, 89% of Medicare Advantage Plans include prescription drug coverage in 2022. Most of these plans are Health Maintenance Organizations or Preferred Provider Organizations . In fact, if you join an HMO or PPO, you will not be able to purchase a standalone Medicare Part D prescription drug plan .

Part C plans with prescription drug coverage must follow Medicares rules but may have different formularies and preferred pharmacies. Your out-of-pocket costs for drugs do not apply toward your maximum out-of-pocket limit.

Enroll In A Medicare Part D Plan

What Prescription Drugs Does Medicare Part D Cover?

According to the official U.S. government website for Medicare, Medicare Part D is a form of insurance that provides prescription drug coverage to beneficiaries of Original Medicare and selected Medicare Cost Plans, Private Fee-for-Service Plans, and Medical Savings Account Plans. You must have either Medicare Part A or Medicare Part B in order to qualify for a Medicare Part D plan.

The official U.S. government website for Medicare also reports that all Medicare Part D plans must offer coverage for a wide range of prescription medications that people on Medicare commonly take. This includes most medications that are in selected protected classes, such as those used to treat cancer and HIV/AIDS.

âEvery Part D plan has a different formulary , and that formulary can change each year,â Matthew Claassen, CEO of Medigap Seminars Insurance Agency, tells WebMD Connect to Care.

Additionally, each planâs formulary will typically be divided into tiers, with the lower tiers containing relatively cheaper drugs and the higher tiers containing more expensive ones.

âSome Part D plans are designed for people with few or no prescriptions and have a formulary that emphasizes lower-tiered drugs. Some are designed for people who have very expensive prescriptions,â Claassen explains.

In the latter case, Claassen notes, the plans âare designed to get a person into âcatastrophic coverageâ fast, so that Medicare pays 95 percent of the prescription costs.â

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Who Is Eligible For Part D Of Medicare

The eligibility requirements for Part D are the same as for original Medicare, and they are as follows:

  • Being 65 or older.
  • Received Social Security disability benefits for a period of, at least, 24 months.
  • Diagnosed with amyotrophic lateral sclerosis .
  • Diagnosed with end-stage renal disease or kidney failure.
  • Having received Social Security disability for at least 24 months.

You can buy a standalone Part D drug plan, or get Part D coverage through Medicare Advantage plans, depending on your medication needs.

Open enrollment for Part D plans begins on October 15th and ends on December 7th, You can enroll in a new Part D plan, or switch from your current plan to a new one once a year, during this period.

You can change your Medicare Advantage plan to include Part D coverage from January 1st to March 31st of each year. During this period, you can also switch from an Advantage plan to a traditional Medicare plan.

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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Medicare Plans In Illinois

Know your options for Medicare plans in Illinois, whether youre looking for Original Medicare or Medicare Advantage.

  • VII.

Illinois has more than 2.2 million people enrolled in Medicare and the number of plan options is also growing. Comparing the different plans is key to finding the best plan for you.

  • Original Medicare
  • Medicare Advantage
  • Medicare Part D

You may also elect to add a Medicare Supplement Plan to go along with Original Medicare to help with additional out-of-pocket expenses.

Before you pick a plan, learn about your costs, coverage, and choosing the best Medicare plan for your needs.

  • Average costs of Medicare in Illinois: In 2022, Medicare Advantage premiums decreased 8.68% from $14.05 to $12.83. The lowest Part D plan in Illinois is $6.90.
  • Average expenditure per enrollee: In Illinois, the average Medicare spending per enrollee is $10,763.
  • Number of enrollees in Illinois: As of 2022, 2,284,894 individuals enrolled in Medicare are in the state of Illinois. Approximately 600,000 individuals are on a Medicare Advantage Plan.
  • Medicare Advantage availability: Illinois has had a 14.50% increase in Medicare Advantage Plans since 2021. There are 166 Illinois Medicare Advantage Plans available in 2022, which is an increase from 145 plans in 2021.

How To Get Extra Help

What prescriptions does Part D cover?

Depending on your income, you may qualify for Extra Help. Extra Help is a program that assists those with limited resources in paying for their Medicare prescription drug costs.

You may automatically qualify for Extra Help if you have Medicare and are enrolled in any of the following programs:14

  • Full Medicaid coverage
  • Assistance from your state Medicaid program for covering Part B premiums
  • Supplemental Security Income benefits

any time.

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What Is Medicare Part D

There are four parts to the Medicare program:

  • Part A, which is your hospital insurance
  • Part B, which covers outpatient services and durable medical equipment
  • Part C, or Medicare Advantage, which offers an alternate way to get your benefits under Original Medicare
  • Part D, which is your prescription drug coverage

Because there is very little prescription drug coverage in Original Medicare, Congress created Part D as part of the Medicare Modernization Act in 2003. Medicare Part D is designed to help make medications more affordable for people enrolled in Medicare.

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