Medicare Insurance Part D
Part D is Medicare regulated and approved prescription drug coverage offered by private insurance companies. Unless you have other creditable drug coverage, you should enroll in Part D when you first become eligible to avoid penalties. Part D was designed in part to help Medicare enrollees to lower their prescription drug costs and to protect against future costs.
It also provides access to medically necessary drugs via a Medicare-approved prescription drug plan. Keep in mind that a plans premium , drug formulary , and copay amounts will vary by plan and by the insurance carrier.
Medicare Part D plans are required to follow the same structure designed by Medicare: Annual Deductible, Initial Coverage , the Coverage Gap or donut-hole, and Catastrophic Coverage.
Medicare Part D coverage can be obtained by purchasing a stand-alone drug plan or by purchasing a Medicare Advantage plan that includes Part D coverage as part of the plan. However, patients cant be enrolled in both plans at the same time.
This insurance covers prescription drugs at a retail pharmacy with benefits that must be equal or better than defined by Medicare. This means a private insurer must meet a certain level of coverage. This includes deductibles, copays, and out of pockets limits associated with the plan.
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.
The Medicare Prescription Drug Coverage Gap
Most Medicare Part D plans have a coverage gap, sometimes called the Doughnut Hole. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for the drugs, up to a yearly limit. Your yearly deductible, coinsurance or copayments, and what you pay while in the coverage gap all count toward this out-of-pocket limit. The limit does not include the drug plans premium or what you pay for drugs that are not on your plans formulary or prescription drug list.
There are plans that offer some 250coverage during the gap, like for generic drugs. However, plans with gap coverage may charge a higher monthly premium. Check with the plan first to see if your drugs would be covered during the gap.
Once a person reaches the plans out-of-pocket limit during the coverage gap, catastrophic coverage automatically kicks in. Catastrophic coverage assures that once a person has spent up to the plans out-of-pocket limit for covered drugs, he or she will only pay a small coinsurance amount or a copayment for the rest of the year.
It is important to note that people who get Extra Help paying drug costs will not have a coverage gap and will pay a small or no copayment once they reach catastrophic coverage.
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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 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
Highlights From The Medicare Part D Drug List For 2022
The Centers for Medicare and Medicaid Services, also known as CMS, released the new details for the changes, which will take place in 2022 on April 2, 2021. These details include information on new deductible amounts and coverage limits, brand-name and generic prescription drug discounts, increased out-of-pocket costs, and how these changes for 2022 will affect the Medicare coverage gap.
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When Should You Enroll In Part D
The best time to enroll in Part D coverage is during your Initial Enrollment Period. If you do not enroll in prescription drug coverage when youre first eligible for it, and you dont have other creditable drug coverage through an employer, union, or group, you may have to pay a late fee when you decide to enroll later on.
What Is The Tier System For Medicare Part D
Every Part D plan formulary has a tier or step system. Think of it as a pyramid. The medications at the bottom of the pyramid are less expensive and the ones at the very top are the most expensive. Most plans have four to six tiers.
Medicare part d tier system
Heres how a formulary tier system works:
- Tier 1: preferred generic medications
- Tier 2: preferred brand name medications
- Tier 3: non-preferred brand medications
- Tier 4 and higher: specialty, select, high-cost medications
Medications on the tiers can be different for each plan, so its good to know where your medications fall within the tier system of the specific plan you are considering. Copays and coinsurance can vary based on tier level as well.
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The Part D Donut Hole
Part D involves a unique structure that results in something known as the donut hole, or more simply the coverage gap. When you have Part D, your coverage is split into three parts: initial coverage, the donut hole, and catastrophic coverage.
Once you reach a certain amount of coverage paid by your plan, you will enter the coverage gap. At this point, you will have to pay higher out-of-pocket costs. The exact breakdown is slightly complicated, and Medicare.gov provides a full analysis of costs in the coverage gap.
For most people, the coverage gap won’t be a huge burden due to the way the costs are distributed. But, it’s important to understand the details if you suspect you’re nearing the end of your initial coverage period.
The Four Phases Of Part D
There are four stages or phases when paying for prescription drugs under Medicare Part D insurance plans. The one consistent aspect is all plans must meet a standard minimum benefit as determined by Medicare. That means every plan has to be approved by the agency.
Stage 1 Deductible: This is the deductible period of Medicare Part D insurance coverage. In 2020, the most any plan can charge is $435, but some plans can go as low as no deductible at all. During this stage, you are responsible for the full cost of your medication until you meet your plans set deductible.
Stage 2 Initial Coverage Period: Once stage 1 deductible is met, the coverage kicks in. Members pay a portion of the prescription cost while the plan picks up the rest of the bill. Obviously, out of pocket costs are less during this stage, but there is a cap.
Stage 3 Coverage Gap: When the monetary cap of stage 2 is met the amount changes on a yearly basis members may experience a coverage gap, popularly known as the donut hole. While its important to note that not all patients reach this stage, those that do can expect to pay more for their medication. However, if particularly expensive or specialty prescriptions are needed on a daily basis, there is some relief.
All costs associated with Plan D insurance reset Jan. 1. That means all patients go back to stage 1. There are ways to keep costs down, however. Each plan has a formulary, a list of drugs that are covered by Medicare Part D insurance.
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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.
What Does Medicare Part D Cover
Each Medicare Part D plan uses a list of approved drugs to decide whats covered and what isnt. This list is called a . Generally, drugs in a lower tier will cost less than drugs in a higher tier. Here is one example of a typical Medicare drug plans tier system :3
- Level or Tier 1: Preferred, low-cost generic drugs
- Level or Tier 2: Nonpreferred and low-cost generic drugs
- Level or Tier 3: Preferred brand-name and some higher-cost generic drugs
- Level or Tier 4: Nonpreferred brand-name drugs and some nonpreferred, highest-cost generic drugs
- Level or Tier 5: Highest-cost drugs including most specialty medications
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Shifting The Cost Of Medication To The Drug Companies In 2022
Starting on January 1, 2020, the Donut Hole was closed completely.
The Donut Hole, which has been around since Medicare Part D began back in 2006, was initially created to keep down the overall out-of-pocket costs for Medicare recipients and the federal government.
But for those on Medicare who rely on brand-name prescriptions, it has been more of a disadvantage than a benefit. Beneficiaries were forced to choose between paying for expensive medication that worked well or paying less for medication that wasnt as useful for treating their health condition.
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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Your Medicare Part D Rights
If you have a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, you have the right to:
- Receive âcoverage determinationâ â a written explanation from your plan about your benefits, including how drugs are covered, your costs for drugs, any coverage requirements (such as drugs that require the planâs prior authorization, and requirements for making coverage exceptions.
- Ask for exceptions to drugs not covered by your planâs formulary.
- Ask for exceptions to waive plan coverage rules .
- Ask for a lower copayment for higher-cost drugs if you or your prescriber believe you cannot take any of the lower-cost drugs for the same condition.
Do you have more questions? Connect with any of our licensed insurance agents to answer your Medicare questions or discuss a Medicare plan option that may be right for you.
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Geisinger Gold Triple Tier For Employer Groups Plans
The Geisinger Gold Triple Tier Formulary for Employer Groups benefit assigns each prescription medication to one of three tiers. Each Tier has a different copayment or coinsurance amount. In general, the higher the cost-sharing tier, the higher your cost for the drug. Cost-sharing amounts are determined by your employer. Contact your employer with questions.
to view the printable 2022 Geisinger Gold Rx Triple Tier for Employer Groups Formulary
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Medical Equipment Used To Administer Medications
- Infusion pumps
- Nebulizer machines
* Oral chemotherapy and anti-nausea agents have to meet certain criteria to be covered by Part B. While the majority of injectable medications will be covered by Part B, keep in mind that some drugs may be excluded. The coverage requirements change on an annual basis.
** Hepatitis B risk factors for the purpose of Part B coverage include diabetes mellitus, ESRD, hemophilia, living with someone who has Hepatitis B, or being a healthcare worker who could be exposed to blood or other bodily fluid.
Does Medicare Cover Cataract Surgery
Cataracts cloud the lens of the eye, making it difficult to see. Surgery is generally needed to correct the condition, although mild cataracts might not require surgery. If your doctor only recommends corrective lenses without surgery, the same parameters described above would apply .
But assuming you need cataract surgery, Original Medicare will cover most of the cost. Cataract surgery is almost always an outpatient service, so its covered under Medicare Part B. That means you pay the Part B deductible and 20% of the rest of the Medicare-approved cost for the cataract surgery.
Additionally, Medicare Part B will pay for a pair of corrective eyeglasses or contacts that are necessary following cataract surgery, with you paying the normal 20% coinsurance that applies to all services covered under Part B.
Depending on your vision needs, you may be offered upgraded intraocular lenses that will correct your vision as well as eliminating the cataract. If you choose this option, you have to pay the additional cost yourself, but Medicare will still pay the amount it would have paid for you to have basic intraocular lenses inserted during the cataract surgery.
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The Cost Of Generic Drugs For Medicare Recipients In 2022
For Medicare Part D plan members who take generic prescription drugs, the cost of your medication will be less once you reach the donut hole. In 2018, the generic drug discount for Medicare recipients was at 56%.
This discount went up to 63% in 2019. This discount applies to any generic prescription. All out-of-pocket costs that you pay out apply to your out-of-pocket spending limit for the year. Once you reach that limit, you will leave the donut hole.
How Parts B And D Work Together
Medicare Parts B and D pay for medications you receive in the ambulatory setting but they won’t pay towards the same prescription. You can only turn to one part of Medicare or the other. However, you may be able to use them both for drugs you receive in a hospital setting.
Medications you receive in the hospital when you are admitted as an inpatient will be covered by your Part A deductible. It is important to understand what happens when you are evaluated in the emergency room and sent home or are placed under observation, even if you stay overnight in the hospital. In this case, you can turn to Parts B and D to pay for your drugs.
When you are placed under observation, Part B will still pay for the medications reviewed above. If you receive IV medications, these will generally be covered. However, you may also receive oral medications during your observation stay that are not on the Part B list of approved medications. In this case, you will be billed for each pill administered by the hospital.
Send copies of your hospital bills to your Part D plan for reimbursement. Unfortunately, if you receive a medication that is on your Part D formulary, your plan may not pay for it.
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What Medicare Part D Drug Plans Cover
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes, like drugs to treat cancer or HIV/AIDS. A plans list of covered drugs is called a formulary, and each plan has its own formulary. Many plans place drugs into different levels, called tiers, on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
What Is The Difference Between Part B And Part D Drugs
Medicare Part B covers drugs that usually are not self-administered. That is, they are given by a doctor or other health care professional in a doctors office, other outpatient facility or at home by a home health aide or caregiver. These drugs are generally administered by infusion or injection.
Medicare Part D covers drugs that are prescribed by your doctor and then filled at a pharmacy and are self-administered. These can include both oral and injectable drugs.
As mentioned above, Part B is one of the two parts of Original Medicare . Original Medicare is publicly funded and provided by the federal government. Medicare Part D prescription drug plans and Medicare Advantage plans that include drug coverage are sold by private insurance companies, though they are regulated by the Centers for Medicare & Medicaid Services .
Medicare Part D coverage can exist as a standalone plan or as part of a Medicare Advantage plan .
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