Ashford Insurance

Medicare Prescription Drug Plans

Prescription Drug Plans Made Easy

Medicare Prescription Drug Plan (Part D) . These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

Medicare prescription drug coverage is an optional benefit offered to everyone who has Medicare. 

Medicare Part D Prescription Drug Plans is coverage for retail prescription drugs or the medications that you pick up at a pharmacy. This is a voluntary program which allows you to access medications at an affordable rate and insures yourself against any prescriptions you may need future.

All Medicare Prescription Drug plans cover the types of drugs most often prescribed for people enrolled in Medicare. This is decided by the U.S. government. But it’s up to each plan which specific brand name and generic drugs they will cover within those types. You can find this information by viewing a plan’s drug list.

Medicare Part D costs vary depending on the specific drug plan chosen. Generally, you are responsible for paying a monthly plan premium, and then deductibles and copays (or coinsurance) for your medications. People with higher incomes may have to pay more for the cost of their plan.

Two ways to get prescription drug coverage

  1. Medicare Prescription Drug Plan (Part D) . These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
    Medicare Advantage Plan (Part C) like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.
  2. There are many Texas Medicare Part D plans to choose from, with plans ranging from $15.00 – $100.00 on up. Choosing your drug plan should never be based purely on the plan’s monthly premium because every plan has its own separate premium, drug formulary, and copay.  Just enrolling in the cheapest plan without checking the plan’s formulary could lead you into paying higher out of pocket costs for the year. This could be an expensive mistake especially if you learn later that the plan does not cover one of your medications. Remember, the least expensive monthly premium is not necessarily the least expensive plan when figuring in total prescription costs. Also, do not forget, all Part D plans, the benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.

Extra Help

The federal government offers extra help with paying for your Part D drug plan and paying for your medications if you qualify and is based on income. This is what is called a Low-Income Subsidy. Anyone can apply for this from Social Security at any time. Help is only awarded based on proving low-income and limited resources. You must have an annual income that falls below 150% of the Federal Poverty Level based on your household size.

Beneficiaries who qualify may receive assistance with paying their monthly Part D premiums, their annual Part D deductible, and also their co-payments on retail medications. There are different levels of qualification, and your subsidy level generally determines how much assistance you will get towards your premiums. Someone qualifying with a full subsidy would have 100% of their Part D premium paid for, up to the benchmark allowed by Medicare for that particular year.

A drug list—sometimes called a formulary—is a list of drugs covered by a plan.

  • A drug list can change from year to year.

    Part D plans may add or remove drugs from their drug list each year. Changes may also be made during the year, for example, if a drug is taken off the market. Your plan will let you know if a change affects a drug you are taking.

  • Many Part D plans have a tiered drug list where drugs are divided into groups based on cost.

    In general, drugs on low tiers cost you less than drugs on high tiers. Plans may charge a deductible for certain drug tiers and not for others, or the deductible amount may be different depending on the tier.

There are rules for some prescription drugs that limit how and when a plan will cover them. These are called requirements or limitations. If you don’t follow these rules or don’t get permission from the plan saying you don’t have to (called an exception), you may have to pay the full cost of the drug out of your own pocket.

The Gap

The Medicare coverage gap, or “Donut Hole“, is a phase of your Medicare Part D Prescription Drug Plan benefit when there is a gap in the prescription drug coverage. During this phase, you will have to pay more for your drugs, until you reach the catastrophic coverage phase. This coverage gap is reached when your initial phase total drug costs (what you and your plan pay) reach a $3,820 for 2019. You then pay for your prescriptions out of pocket until entering the plan’s catastrophic coverage phase. This third phase is when your total out-of-pocket costs, including the annual deductible and co-payments/coinsurance, reach $5100 in 2019.

Some Texas Medicare Advantage Prescription Drug plans and stand-alone Medicare Prescription Drug Plans provide partial or full coverage during the coverage gap. For example, some plans may not have a gap at all, while others may offer generic drug coverage in the gap. Plans with gap coverage may charge a higher monthly premium, so you should only consider one of these plans if you have high prescription drug costs and know you will reach the coverage gap.

There is a Late Enrollment Penalty for not having creditable Prescription coverage. 

Ashford Insurance also offers Medicare Advantage (Part-C) and Medicare Supplements (Medigap) insurance Plans.

Sarah began working in the healthcare industry in 2001, where she worked for many years with elderly Alzheimer and Dementia patients. From there she worked as a Group Benefits Administrator with a local healthcare company in the Human Resource Department for a period of 10 years. Since then, she has decided to work in the Medicare insurance industry full time and has joined the family business, Ashford Insurance, as a Medicare Insurance Agent.

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Email Sonia@ashfordinsurancegroup.com

* A licensed sales agent may call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.