How To Get Prescription Coverage With Medicare

What Questions Can You Expect To Be Asked

Regardless of your enrollment method, you have to answer a couple of basic questions. They include:

• Your Main Address: The address for your primary residence and which is included in your tax form and drivers license. This ensures that you only apply for one prescription drug coverage. You should provide the address that is within the service area of the plan you opt for.

• Your Present or past Drug Coverage: This ensures that all your other benefits are coordinated with Part D. It also ensures that you confirm to accept any consequences of joining Part D. This is important if the coverage may affect your other Medicare plans adversely.

• How would you prefer to pay for your Premiums? You can have the plan bill you directly or have the premiums deducted from your social security check automatically. Alternatively, you can choose to have your bank wire the funds to the plan automatically. Once you make a selection, you have to stick with it for the rest of the year.

How To Get Prescription Drug Coverage With Medicare Insurance

Most Americans need prescription drugs either on an as-needed basis or as a part of their regular health regimen. Seniors, in particular, rely on prescription drugs to stay healthy. Medicare drug coverage helps kupuna with the cost of the prescription drugs they need so they dont have to pay 100% out of pocket. If you are getting ready to retire and switch to Medicare insurance, you should be considering your prescription drug coverage options. If you decide not to get it when you are first eligible and dont have other creditable prescription drug coverage or Extra Help, you could end up paying a late enrollment penalty.

When Can I Enroll In A Medicare Prescription Drug Plan

You can enroll in a plan at any time during your Medicare Initial Enrollment Period, which starts three months before your 65th birthday month, includes your birthday month, and extends for three additional months. If you get Medicare because of a disability, you can generally enroll in Medicare Part D after you are on Social Security disability for 24 months.

You can make changes to your prescription drug coverage each year during the Fall Open Enrollment Period . If you get Medicare Part D as part of your Medicare Advantage plan, you can also make changes during the Medicare Advantage Open Enrollment Period which runs from January 1st through March 31st.

Its important to enroll in a plan when you are first eligible if you want to avoid a late enrollment penalty with your monthly premium. If you go without creditable prescription drug coverage and you dont enroll in Part D when you are first able, youll pay a penalty of 1% of the national base premium for each month you go without coverage. You pay this penalty for as long as you have Medicare Part D coverage.

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Do I Need Medicare Part D

Medicare Part D is technically voluntary coverage you arent required to enroll in a plan. However, if you go without prescription drug coverage before you enroll in a plan, you may pay a late penalty with your monthly premium. If you have prescription drug coverage through an employer group or retiree plan, you dont have to enroll in a Medicare Part D plan until your coverage ends.

Does Medicare Cover Enbrel

Yes! 76% of Medicare Advantage plans and Medicare Part D plans cover Enbrel.1

• Medicare Advantage plans that offer prescription drug coverage are called Medicare Advantage Prescription Drug Plans . Most Medicare Advantage beneficiaries are enrolled in MA-PDs.2
• Medicare prescription drugs plans each have their own formulary, or drug list, that details what prescription drugs are covered by the plan and how they are covered.

Drug coverage may vary based on plan availability. You may be able to find Medicare Advantage plan options in your area that cover Enbrel.

Find Medicare Advantage plans with drug coverage

Or call 1-800-557-6059TTY Users: 711 24/7 to speak with a licensed insurance agent.

You can also compare Part D prescription drug plans available where you live and enroll in a Medicare prescription drug plan online when you visit MyRxPlans.com.

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Introduction To Medicare Part D

This section constitutes an introduction to Part D. For more detailed information on any of the topics in this section, please click on the links within the topics. There, you will also find relevant legislative, statutory and CFR citation.

Prior to 2006, Medicare paid for some drugs administered during a hospital admission , or a doctors office . Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit, authorized by Congress under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This Act is generally known as the MMA.

The Part D drug benefit helps Medicare beneficiaries to pay for outpatient prescription drugs purchased at retail, mail order, home infusion, and long-term care pharmacies.

Unlike Parts A and B, which are administered by Medicare itself, Part D is privatized. That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy offered by one of these companies.

The costs associated with Medicare Part D include a monthly premium, an annual deductible , co-payments and co-insurance for specific drugs, a gap in coverage called the Donut Hole, and catastrophic coverage once a threshold amount has been met.

There Are Two Paths To Medicare Part D

When you first enroll in Medicare you must choose between original Medicare or Medicare Advantage. That decision impacts how you can get prescription drug coverage through a Part D plan.

If you enroll in original Medicare, you need to purchase a separate Medicare Part D plan from a private insurer. If you choose to enroll in a Medicare Advantage plan, your Part D coverage is typically included. In cases where its not included in Medicare Advantage plans, you can purchase a separate Medicare Part D plan.

Regardless of which Medicare program you opt fororiginal or Advantageyou typically have at least two dozen different Medicare Part D plans to choose from.

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Do I Get Prescription Drug Coverage With Disability Ssdi

You don’t directly get prescription drugcoverage with Social Security Disability Insurance. Social Security will mainlypay disability benefits when you have sufficiently proved that you are indeeddisabled, based on the eligibility criteria they have.

However, if you have been receivingdisability benefit payments for 24 months, you may become eligible underMedicare and receive medical benefits, including prescription drug coverage. Youneed to sign up for this coverage. You are required to sign up within theperiod covered by three months prior to your 25th month receivingSocial Security disability benefits up to the three months after your 25thmonth. Confusing? This just means that you can sign up between the 22ndmonth to the 28th month that you are receiving Social Securitybenefits. You need to do this. Otherwise, you may also need to pay a penalty.

The Medicare benefits provided include:

• Medicare Part A benefits
• Medicare Part B (covering mainly outpatient services and other expensesnot covered by Medicare Part A
• Medicare Part D
• Other optional plans such as Medicaid

This is not just for the disabled beneficiary,but also for his dependents. Also, the prescription drug coverage covers notjust generic prescription drugs but also brand-name medications.

In 2010, the beneficiary will receive arebate of $250 when his medication expenses exceed $2,700. Come 2011, discountsof up to 50% will be given for medicines, particularly brand-name drugs.

Do I Need Part D Prescription Drug Plan

In most cases, its a good idea to at least consider a Part D prescription drug plan during your Medicare Initial Enrollment Period. If you delay, you will have to pay a late enrollment penalty if you decide later to join a Part D plan.

Generally, it makes good sense to enroll in a Part D plan if:

• You use prescription drugs regularly
• You may need prescription drugs in the future
• You do not have creditable prescription drug coverage
• You are concerned about rising prescription drug costs
• You have trouble paying for your prescription drugs.

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Is Your Workplace Drug Coverage Creditable

If you are working past age 65 and have coverage through work, you need to ask HR if the drug coverage in your workplace plan is considered creditable by Medicare. For a plan to be creditable it must offer benefits that are at least as good as what is covered by a basic Part D Medicare plan. If the answer is yes get it in writing and staying on the workplace plan is cheaper than starting Medicare, you can stick with it. retiree health insurance benefits. If at some point you want to switch to Medicare coverage, your prior coverage will entitle you to get a Plan D drug plan without any penalty.)

The minute you stop working post-65, or the minute the plan bumps you from coverage post-65, you need to be aware of a maddening quirk in Medicare rules.

You have up to eight months to sign up for Medicare Part B without any premium penalty. But you only have two months to sign up for Medicare Part D, without the penalty formula kicking in.

What Is The Donut Hole Gap In 2020

In 2011, the government took several actions that started to close the donut hole. These included:

• 2011: The Affordable Care Act required pharmaceutical manufacturers to introduce discounts of up to 50% for brand name drugs and up to 14% for generic drugs, making it easier for people to buy medications once in the donut hole.
• 20122018: The discounts continued to increase.
• 2018: The Bipartisan Budget Act sped up changes to prescription drug discounts when a person was in the donut hole. Examples included manufacturer discounts and decreasing a persons costs on brand name drugs once they enter the donut gap.

The aim of these changes was to make drugs more affordable once a person reached the donut hole, which would encourage people to continue taking their medications and reduce the risk of a break in treatment. As of 2020, prescription drug coverage takes the following shape:

Ideally, these changes will allow a person to have long-term access to the medications their doctor prescribes.

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Two Ways To Get Prescription Drug Coverage

Original Medicare does not cover most prescription drugs. Part A only covers certain drugs during an inpatient stay. If you want a plan that offers prescription drug coverage, you have two options.

Option 1: A Medicare prescription drug plan

Option 2: A Medicare Advantage plan with included drug coverage

Both types of plans are offered by private insurance companies approved by Medicare and will vary in costs and coverage.

When And How Do I Enroll In Medicare Part D

The first opportunity for Medicare Part D enrollment is when youre initially eligible for Medicare during the seven-month period beginning three months before the month you turn 65.

If you enroll prior to the month you turn 65, your prescription drug coverage will begin the first of the month you turn 65. If you enroll during the month you turn 65 or one of the three following months, your prescription coverage effective date will be delayed it will not be retroactive to the month you turned 65.

If you enrolled in Medicare due to a disability, you may enroll during a seven-month window beginning three months prior to your 25th month of disability. If you enroll in the three months prior to your 25th month of disability, your coverage will begin the first day of the 25th month. If you enroll during the 25th, 26th, 27th, or 28th month of disability, your coverage will begin the first of the month after you enroll .

Heres more information on how to pick a prescription drug plan.

In both of these cases whether youre turning 65 or are eligible for Medicare because of a disability you have the option of selecting a Medicare Advantage plan that includes prescription drug coverage, and using that in place of Medicare A, B, and D. The enrollment periods and rules are the same as those described above for stand-alone Medicare Part D plans.

After youve chosen from the various PDP offerings, you can enroll by:

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Find A Medicare Drug Plan In Your Area

Use the online Medicare Plan Finder tool for a list of the stand-along Part D plans and Medicare Advantage plans with drug insurance available in your ZIPcode.16 The comparison tool shows the drugs covered by each plan, cost-sharing amounts, and whether you need prior authorization and preferred pharmacies.

Drugs Not Covered By Part D Plans

There are many drugs that Medicare plans will not cover under the Part D benefit, based on national Medicare guidelines. These include, but are not limited to:

• Drugs for anorexia, weight loss, or weight gain
• Fertility drugs
• Ingredient/adjuvant such as sterile water for injection
• IV line flush such as normal saline IV flush
• Medical supplies
• Drugs covered under Medicare Part A or Part B

Prescription drugs used for the above conditions may be covered if they are being prescribed to treat other conditions. For example, a medicine to relieve cold symptoms may be covered by Part D if it is used to treat something other than a cold as long as the FDA approves the drug for such treatment.

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How Does A Tiered Formulary Work

Many plans have a tiered formulary where the plan’s list of drugs are divided into groups based on cost. In general, drugs in low tiers cost less than drugs in high tiers. Additionally, plans may charge a deductible for certain drug tiers and not for others, or the deductible amount may differ based on the tier.

Formulary tiers:

The Part D Standard Benefit

At a minimum, plan sponsors must offer a standard benefit package mandated by law. The standard benefit includes an annual deductible and a gap in coverage, previously referred to as the Donut Hole. Sponsors may also offer plans that differ from but are actuarially equivalent to the standard benefit. Finally, they may also offer enhanced plans that provide benefits in addition to the standard benefit. Typically, the enhanced plans offer some coverage during the Donut Hole.

The Standard Benefit is defined in terms of the financial structure of the cost-sharing, not the drugs that must be covered under the plan.

Medicare does not establish premium amounts for plans. Instead, premiums are established through an annual competitive bidding process and evaluated by CMS. Premiums vary from plan to plan and from region to region. Medicare does establish the maximum deductible amount, the Initial Coverage Limit, the TrOOP threshold, and Catastrophic Coverage levels every year. The table below shows the standard benefit for this year .

Standard Part D Benefit 2020-2021

Alternatives to the Standard Benefit

Income-Related Monthly Adjustment Amount Part D

Income-Related Adjustments 2021

Drug Tiers

The Donut Hole

TrOOP

Once beneficiaries reach their out-of-pocket threshold costs), they move out of the Donut Hole and into Catastrophic Coverage.

EOBs

The Donut Hole Discount

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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 2021, 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

When To Sign Up For Medicare Part D

If you dont have prescription drug coverage through an employer or former employer, you should sign up for Medicare Part D right when you sign up for Medicare Part B during your initial enrollment period .

If you dont sign up for Part D during your initial enrollment period, you can sign up during the annual enrollment period for coverage that starts the next year. But keep in mind, theres a penalty for missing your IEP.

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How Will You Know If Your Enrollment Has Been Accepted Or Denied

10 calendar days after your application, the plan has to send you any of the following:

• Acknowledgment of your submitted application, its copy, and the plans details

• Request for more details to process your application that you should offer within 30 days

• Notice of your denial which should state why you have been denied

Which Medicare Part D Plan Is Right For You

Medicares free online tool enables you to search for plans offered in your area. You can enter the specific drugs you currently take and then get a cost comparison across plans based on each plans specific formulary, tier system, and whether they charge copays or coinsurance.

As noted earlier, if you opt for Medicare Advantage, your Part D coverage will most likely be included in the plan you choose. But here too you want to carefully comparison shop for the plan with the best drug coverage based on your individual needs. Hint: you and a spouse might choose different Medicare Advantage plans based on your medication needs.

Independent insurance agents that specialize in Medicare can also help you sort through all the moving pieces for plans offered in your area.. Free counseling is also available through your State Health Insurance Assistance Program .

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