Medicare contracts certain private insurance companies who provide Medicare Prescription Drug Plans. These plans will supply and coordinate prescription drug benefits to you as a beneficiary. You have two options if you want to get prescription drug coverage (Medicare Part D):
- If you have Original Medicare, you can get a stand-alone Medicare Prescription Drug Plan.
- Or you can get it through a Medicare Advantage Prescription Drug plan.
Your prescription drug coverage will depend on the Medicare Prescription Drug Plan that you choose. This is because private insurance companies contracted with Medicare offer these plans, so they vary. The benefits and drugs that they will pay for are determined by the insurance company.
“Tiers” mean the amount you owe out of pocket for the Part D drugs represented in each tier. There are different levels of “tiers” under the Prescription Drug Plan. For instance, the plan might have one tier for brand-name drugs, a second tier for preventative drugs, and a third tier for generic drugs.
A “formulary” is a list of prescription drugs that the drug plan covers. These drugs will be under the Medicare Advantage Prescription Drug plan or the Medicare Prescription Drug plan. Please note that formularies are subject to change year after year. If needed, your Medicare plan will notify you if formularies change.
If a prescription drug costs less at a higher level, typically those are the drugs that your plan will cover. This means your out-of-pocket amount will be lower. If you know what drugs are on your prescription drug plan, it’s best to ask your doctor to prescribe you those specific drugs. Generally lowest priced drugs are generic.
What are the Changes in a Part D formulary
A requirement of every Medicare Prescription drug plan is to post its formulary on their website. If the plan takes out drugs from the Part D formulary, it must also inform you. At any time the formulary can change. Your plan will give you a notice when the formulary changes.
From the beginning of the plan’s annual election period until 60 days after the plan coverage starts — Medicare Prescription Drug plans cannot make changes to the tiered pricing or the listed drugs. However, if a manufacturer eliminates a drug from the market or the FDA decides a drug is unsafe, then this is the exception to the rule.
If your plan makes changes to the formulary drugs mid-year, your plan must notify you of those changes. There are restrictions on how many changes a plan can do Mid-year. The following is what the plan must notify you of:
- The reason for the change
- The name of the drugs
- New Part D cost sharing
- Part D change type (e.g, tier change/remove/add)
- Alternate drugs
- Exceptions
Drugs paid for under Medicare Part D
Vaccine drugs when needed to prevent illness are all under the Medicare Prescription Drug Plan and Medicare Advantage Prescription Drug plan coverage. The plan will decide which tier each drug goes under, which drugs to pay for and which drugs not to pay for.
If you want a certain plan, read the plan’s formulary and the plan’s coverage for each drug. Do this before you enroll in a Medicare Advantage plan that includes drug coverage or a Medicare Prescription Drug Plan.
Drugs that are not paid for under Medicare Part D
The following are the drugs that Medicare Part d usually does not cover. This list can include more since each plan is different, but below is basically what the plans do not cover:
- Over-the-counter drugs
- Fertility drugs
- Drugs for sexual or erectile dysfunction
- Drugs for hair growth or cosmetic purposes
- Weight gain or weight loss drugs
If Medicare Part A or Part B covers certain drugs, then Medicare Part D will not cover those.
Your Rights as a Medicare Part D Enrollee
The following are your rights if you have a Medicare Advantage Prescription Drug plan or a Medicare Prescription Drug Plan:
- If you or your provider believe you cannot take any of the lower cost drugs for a condition. Then you can request for a lower copayment for higher-cost drugs for the same condition.
- You can request to turn down plan coverage rules (e.g. prior authorization).
- You can request for exceptions to drugs that are not covered by your plan’s formulary.
- Get “coverage determination” — This explains your plan’s benefits. Which include your drug coverage terms, the amount you will owe for the drugs, and any coverage requirements. These coverage requirements include requirements for making coverage exceptions and the plan’s prior authorization.
If you have any questions then, contact our licensed insurance agents. We will discuss the best Medicare plan option for you and answer any questions you may have.