Your Medication Needs Have Changed
It always pays to find a Part D plan that offers decent coverage for the specific medications you take. But once your prescriptions change, it absolutely pays to see if theres a plan that might offer you a better deal.
For example, if youre paying a relatively high premium for a specific plan that places one of your recurring medications in a relatively low tier, but you then switch to a generic version of that drug thats cheaper across the board, it pays to see if you can get away with paying a lower premium.
Or, if youve switched to another medication thats placed in a higher tier under your current plan, it pays to see if theres another plan that has it in a lower tier.
If youre enrolled in an MA-PD plan and considering a plan change during the Medicare Advantage Open Enrollment Period, make sure you take your current prescriptions into consideration. And youll also want to consider Original Medicare plus a stand-alone Part D plan, to see if that might work best for your situation.
Three Firmsunitedhealth Humana And Cvs Healthcover Nearly 60 Percent Of All Medicare Part D Enrollees In 2019
Figure 3: Distribution of Medicare Part D Enrollment by Firm in 2019
The top three firmsUnitedHealth, Humana, and CVS Healthcover nearly 60 percent of all beneficiaries enrolled in Part D in 2019 , while the top five firmsincluding WellCare and Cignaaccount for three-quarters of Part D enrollment . The recent acquisitions of Aetna by CVS Health and Express Scripts by Cigna have resulted in further consolidation of the Part D marketplace. In particular, between 2018 and 2019, Cigna increased its market share from 3 percent to 8 percent, while CVS Health increased its market share from 14 percent to 17 percent. Under the CVS Health-Aetna merger, Aetna divested its stand-alone PDP business to WellCare, resulting in a more than doubling of WellCares Part D market share, from 4 percent in 2018 to 10 percent in 2019.
The Medicare Part D Donut Hole Coverage Gap
After 2020, Medicare Part D plans have a shrunken coverage gap, or donut hole, which represents a temporary limit on what the plan will cover for prescription drugs.
You enter the Part D donut hole once you and your plan have spent a combined $4,430 on covered drugs in 2022.
Once you reach the coverage gap, you will pay up to 25 percent of the cost of covered brand name and generic drugs until you reach total out-of-pocket spending of $7,050 for the year in 2022.
Once you reach $7,050 in out-of-pocket spending, you are out of the donut hole and enter catastrophic coverage, where you typically only pay a small copayment or coinsurance payment for the rest of the year.
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Get Someone On Your Side With Part D
Please consider enrolling. Make sure to do so through an agency like ours that wont pass you off to Medicare to enroll. Well help you choose a Part D plan if you have your Medigap plan with us. Well support you on the back end of it too. Thats how much we value our Medigap policyholders.
Every year our agency explains Part D plans to thousands of new Medicare beneficiaries who are setting up their Medigap plans through our agency. Theres no need for you to go it alone. We can help you with the best way to insure yourself at the lowest possible cost. Give us a call today for help with all of your Medicare needs.
Con: But It Can Also Be Confusing
If filing a tax return or choosing home insurance leaves you scratching your head, then you can add another source of confusion to your list in the form of Medicare. While the different coverage options offer plenty of choices, that alphabet soup of variety can make it harder for you to figure out whats best for you.
There are also enrollment requirements and timeframes that you need to be aware of. If you miss your initial enrollment period, which begins three months before you turn 65 and runs until three months after, then youll need to wait until a general enrollment period opens up, unless you qualify for special enrollment.
Also, keep in mind that if you fail to sign up for Plan B when you first become eligible and dont have an approved exception, you face penalty premiums for each year you dont register.
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When Can I Enroll In Medicare Part D
You can enroll in Medicare Part D during your Medicare initial enrollment period . This is the same as when you qualify for Medicare in general, which is 3 months before your 65th birthday, your birthday month, and 3 months after you turn age 65.
Some people may qualify for Medicare Part D at an earlier age if they have medical conditions such as amyotrophic lateral sclerosis , end stage renal disease , or a disability that qualifies for Social Security Disability Insurance.
Here is a list of all the times throughout the year when you can join a Part D plan:
- 3 months before your birthday to the 3 months after: this is your IEP
- open enrollment period for Medicare or when you can make changes to your current Part D plan
- the time period you can enroll in Medicare Part D if you have Medicare Advantage, but wish to switch to original Medicare with or without Part D
Con: Some Important Aspects Of Care Aren’t Covered
When youre paying a monthly premium for healthcare services, you may expect everything to be covered, but Medicare Plan A and Plan B fall short here. While they provide a wide range of hospital and medical benefits, they omit coverage of the following:
- Prescription drugs
- Routine dental care or dentures – you’ll still need to look at the best dental insurance
If any or all of the above areas are ones that are important to you, then you may want to consider Medicare Advantage .
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D Is Not A Money Maker For Your Agent
Some of you reading this are thinking Well of course you recommend Part D because agents get paid to sell Part D. Let me shed some light on this.
Part D commissions for agents are so low that most agents will no longer help people with Part D. They just send them to 1-800-MEDICARE to enroll on their own. Why? Because an agent gets paid about $3/month on a Part D policy. An agent would have to write thousands of them just to barely make a living. So I assure you, no agent is getting rich off Part D.
Lazy agents will write your Medigap plan and throw you to wolves on Part D because its not worth their effort.
Medicare Part D Premiums In 2022
Your monthly premium is the amount you need to pay each month in order to continue receiving coverage from your prescription drug plan. Premiums vary by plan but the base monthly premium for a Part D plan in 2022 is $33.37, up from $33.06 in 2021.
If you make more than a certain amount, you will have to pay a higher premium. The extra amount you pay is based on whatâs known as an income-related monthly adjustment amount . The IRMAAs for 2022 were determined by your income on your 2020 tax returns. The table below shows how much you can expect to pay.
How Does The Medicare Part D Drug Plan Requirement Work
EPIC members are required to be enrolled in a Medicare Part D drug plan or a Medicare Advantage health plan with Part D . Enrolling in EPIC will give a member a Special Enrollment Period to join a Medicare Part D drug plan. Medicare Part D provides primary drug coverage for EPIC members. After a Part D deductible is met, if a member has one, EPIC provides secondary coverage for approved Part D and EPIC covered drugs. EPIC also covers approved Part D-excluded drugs such as prescription vitamins as well as cough and cold preparations after enrolling in a Part D drug plan.
The New York State EPIC program is not Creditable Coverage for members. This means that EPIC benefits are not as generous as Medicare Part D. If a member is not enrolled in a Medicare Part D drug plan, the member will not have any prescription coverage from EPIC or receive any EPIC benefits.
Because EPIC is a State Pharmaceutical Assistance Program, EPIC can provide:
- a Medicare Special Enrollment Period so that a new member may enroll in a Part D drug plan at any time during the year
- a Medicare one-time plan change per calendar year for existing members
- co-payment assistance after the Medicare Part D deductible is met, if the member has one. EPIC also covers approved Part D-excluded drugs once a member is enrolled in a Part D drug plan.
What Is The Medicare Part D Coverage Gap In 2022
The Medicare Part D coverage gap, also called the Medicare Part D donut hole, is a temporary limit on how much insurers will pay for your prescription drugs. In 2022, you will enter the coverage gap once you and your insurer have spent a combined $4,430 on prescriptions. This includes copays and coinsurance payments you make, but doesnât include your premiums.
To get out of the coverage gap â meaning your plan will start covering drug costs again â you will need to reach a total spending level for the year. In Medicare, thatâs known as the true out-of-pocket limit, or TrOOP costs, and it includes your copays, coinsurance, and deductibles. In 2021, the TrOOP threshold is $7,050. Once you spend that much, youautomatically get catastrophic coverage. Catastrophic coverage gives you reduced copays and coinsurance for the rest of the year.
Most people enter the coverage gap at some point during the year. Once you do, Medicare will pay for a certain percentage of your drugs and you will have to pay the rest. How much Medicare covers depend on whether you get a generic or brand-name drugs.
For Medicare to cover the cost of brand-name drugs, you have to fill your prescription at a pharmacy or order through the mail. And even though you only pay 25%, 95% of the cost will count toward your out-of-pocket limit.
The Medicare Part D coverage gap can get confusing, so make sure to check your planâs details and to reach out to your insurance company if you have questions.
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How Do I Get Medicare Part D
After you’ve done your research and chosen a plan, you have a few options to sign up. You can enroll on the Medicare Plan Finder or on the plan’s website. You can complete a paper enrollment form or call the plan directly for assistance. Additionally, you can call Medicare at 1-800-MEDICARE . TTY: 1-877-486-2048.
I Have Original Medicare Do I Also Have To Enroll Separately In Medicare Part D Prescription Drug Coverage
En español | Part D drug coverage is a voluntary benefit you are not obliged to sign up. You may not need it anyway if you have drug coverage from elsewhere that is creditable meaning Medicare considers it to be the same or better value than Part D. This coverage could come from an employer or union, retiree benefits, COBRA or the Veterans Affairs health program all of which have an obligation to tell you whether it is creditable. But without such coverage, you need to sign up with a stand-alone Part D drug plan if you want Medicare to help pay for your medications and avoid late penalties.
Stand-alone Part D plans, which are run by private insurance companies but regulated by Medicare, are plans that provide only drug coverage. Therefore they are for people enrolled in the original Medicare program, which doesnt cover outpatient drugs.
You are eligible for Part D coverage if you are enrolled in either Part A or Part B . To join a stand-alone Part D drug plan, you need to select one plan from many available in your area, and pay a separate monthly premium . The costs of coverage premiums, deductibles and copays vary according to the drug plan you choose.
For information on how Part D drug coverage works, see AARPs consumer guide to the program at .
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Where Can A Person Get Their Medication
Medicare requires that Part D plans cover all prescription drugs in these categories:
- anticancer medications
- HIV and AIDS medications
- immunosuppressant medications
Each Part D plan must cover a minimum of two medications in each category. However, the plans can develop their own list of drugs they cover, called formularies. Plans often cover vaccines with no copay.
If doctors prescribe medications that the formulary does not include, they can request an exception. They must send a formal letter to the Part D provider explaining why their patient needs the specific medication. Medicare decides on an individual basis if they will allow the exception.
Plans may use specific pharmacies or network of pharmacies. They may offer options for both retail and mail-order pharmacies that cover the plan holder.
A person can use the online plan finding tool to compare plans, including drug coverage.
Medicare Part D has different associated costs, including a monthly premium, deductibles, and copays. The exact cost of each of these depends on the individual plan.
A basic premium applies to Medicare Part D, although it varies by plan, and a person pays it in addition to the Medicare Part B premium.
A person may also pay an extra amount, called a Part D income-related monthly adjustment amount , depending on their income level.
Most, but not all, Part D plans have a deductible that a person pays out-of-pocket. In 2020, the maximum deductible is $435.
What Happens If You Lose Your Creditable Prescription Drug Coverage
If you retire or are laid off, or your spousal coverage ends, your days of having creditable prescription drug coverage are numbered. However, youll have access to a special enrollment period to sign up for Medicare, including Part D, without penalty. This period lasts for two full months from the time your coverage ends.
This special enrollment period will also apply when COBRA runs out if you enroll in COBRA and retain your former employers creditable coverage.
If your employers coverage changes and is no longer creditable, youll also have a two-month special enrollment period to sign up for Part D without penalty.
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What Is The Medicare Part D Premium Penalty
To avoid Medicare premium penalties, it’s important to know when your initial enrollment period begins. Your initial enrollment period for Medicare starts three months before you turn 65 and ends three months after you turn 65. That means you have seven months, including your birthday month, to enroll penalty-free. For example, if your birthday is in April, your initial enrollment period runs from January 1 through July 31.
From that point on, you can’t go without prescription drug coverage for more than 63 days, or you’ll owe a penalty. The penalty is a lifetime surcharge on your Part D premiums once you enroll.
How To Enroll In Medicare Part D
First, you need to enroll in Original Medicare . If you arenât automatically signed up â meaning youâre 65 but not yet receiving federal retirement benefits â you can enroll in Medicare by visiting your local Social Security office, calling 1-800-772-1213, or completing an online application at the Social Security Administration website.
Then you can find Medicare Part D plans in your area through the Medicare website. When you choose a plan, the site will direct you to the insurerâs website because you have to purchase plans directly from insurers.
However, you can only get a Medicare Part D plan during certain times of the year. New Medicare beneficiaries have a seven-month period that starts three months before their 65th birthday. This is your initial enrollment period. Outside of that, there are three other times you can enroll:
Medicare open enrollment runs from October 15 to December 7 each year. Itâs also called the annual election period .
Special enrollment occurs after a major life event, like a move or loss of coverage. Itâs also known as a special election period .
If you have Medicare Advantage , the Medicare Advantage disenrollment period allows you to drop Medicare Advantage, and revert to Original Medicare. Then you can enroll in a Medicare Part D plan. The MADP is January 1 to February 14.
Learn more on how and when to apply for Medicare.
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Medicare Tracks Your Part D Spending
Its important to note Medicare itself tracks your True Out of Pocket Costs for each year. This can protect you from paying certain costs twice. For example, say you have already satisfied the deductible on one plan. Then you later switch mid-year to a different Medicare Part D plan because you moved out of state. Your new plan will already see that you have paid the deductible for that year. The costs for the coverage gap and catastrophic coverage work the same way.
Part D drug plans also have changes from year to year. Your plans benefits, formulary, pharmacy network, provider network, premium, and/or co-payments/co-insurance may change on January 1st of each year. Medicare gives you an Annual Election Period during which you can change your plan if you desire to do so.