Bedford Prescription Drug Plans

Prescription Drug Plans Made Easy

Part D covers brand-name, generic, and specialty medications. Each plan has a list of drugs it covers, known as a formulary.

Your costs, when enrolled in a Part D plan, include:

Your Part D plan monthly premium, if applicable.
Any out-of-pocket costs such as copays, coinsurance, and deductibles included with the prescription drug plan you choose.
A late enrollment penalty (this applies only if you have a period of 63 days without Part D coverage).

Let’s Talk About Each of the 4 Phases.

This is the period where you must pay a certain amount of prescription costs before your Part D plan kicks in. The maximum deductible a Part D plan can have is announced each year by Medicare. In 2023, the maximum deductible is $505. That doesn’t mean it’s the maximum you’ll pay all year, rather it’s what you owe initially before your plan begins to help pay a portion of your drug costs. Some Part D plans have the full $505 deductible, some have a lower deductible, and some don’t have a deductible at all. It just can’t be higher than $505 in 2023.

Assuming your medications are on your plan’s formulary list of drugs, this is when your Part D plan begins to pay the bulk of a drug’s cost (as high as 75% or more). It’s “Tier-based” pricing. Typically, generic drugs are Tier 1 or Tier 2, and then, brand name drugs are Tier 3, Tier 4, and Tier 5. You will pay tier-based pricing until you reach the Coverage Gap (the Donut Hole), which is when total drug costs reach $4,660 in 2023. Gross drug costs are what you pay, plus what your plan paid on your behalf.

Once your drug costs reach $4,660 you will enter the Coverage Gap (a.k.a. the Donut Hole). This is where you will pay 25% of a drug’s full retail cost. For some drugs (like generics), the cost might not change much. For other drugs (like brand names), the cost could go up substantially because you’re now paying 25% of the full cost. It’s like this until you reach $7,400 of True Out-of-Pocket Costs (TrOOP).
NOTE: $7,400 is NOT a cap or max out-of-pocket limit. See Catastrophic below…

When your TrOOP costs reach $7,400, you will pay no more than 5% of a formulary drug’s full gross cost for the remainder of the calendar year. TrOOP is a combination of:
- Your costs in the Deductible phase
- Your costs in the Initial Coverage phase
- Your costs in the Coverage Gap (Donut Hole) phase
- 70% of the brand name cost in the Coverage Gap (Donut Hole) phase, which the manufacturer pays

You must have Original Medicare Parts A and B to join a Part D plan.

You can join a standalone Part D prescription drug plan. A standalone Part D plan would be in addition to Original Medicare or a Medicare Supplement plan.
Most Medicare Advantage plans include Part D prescription drug coverage. If you have a Medicare Advantage plan, you cannot join a separate standalone Part D plan.

If you have limited income and resources, you may qualify for extra help.

A Late Enrollment Penalty (LEP) is an unwelcome surprise. LEP can be confusing and frustrating.

Late Enrollment Penalty (LEP) Details:

Medicare beneficiaries may incur a late enrollment penalty (LEP) that is added to their Part D premium if there is a continuous period of 63 days or more, at any time after the end of the individual’s Part D initial enrollment period, during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.
Medicare plans that offer Part D benefits are required by CMS to notify enrollees in writing if they determine that a gap in coverage exists as described above.
If a valid attestation is not received by the due date, Medicare will impose the LEP which will be communicated by the insurance carrier.
you have 60 calendar days from the date on the LEP letter to request a reconsideration request of the LEP.