What is Part D?

Medicare’s prescription drug benefit (Part D) is the part of Medicare that provides outpatient drug coverage. Part D is provided only through private insurance companies that have contracts with the federal government—it is never provided directly by the government (unlike Original Medicare).

Unlike private health insurance plans, Original Medicare (Medicare Parts A and B) does not cover prescription drugs. Medicare Part D was established in 2003 to provide prescription coverage for Medicare enrollees and requires buying a private prescription plan.

There are a few avenues for obtaining prescription coverage once you’re eligible for Medicare, which is typically age 65 (or younger if you meet disability qualifications). The options are:

• A stand-alone Medicare Part D Prescription Drug Plan, which can be used in tandem with Original Medicare

• A Medicare Advantage plan that includes Part D prescription drug coverage (these Medicare Advantage plans are known as MAPDs). Most Medicare Advantage plans are MAPDs.
• Supplemental coverage from Medicaid (the coverage will be via Part D) or your employer or a spouse’s employer (including retiree coverage that’s considered comparable to Part D coverage).

Ashford Insurance can help you get the prescription coverage you need.

What is Part D?

Medicare Part D is a federal program administered by private insurance companies. These companies offer retail prescription drug coverage to Medicare beneficiaries. Prior to 2006, when Medicare Part D began, tens of thousands of Medicare beneficiaries in America had no help with the costs of retail drugs, often spending thousands of dollars every year paying for their medications out of pocket. 

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

Medicare Part D is simply insurance for your medication needs. You pay a monthly premium to an insurance carrier for your Part D plan. In return, you use the insurance carrier’s network of pharmacies to purchase your prescriptions. Instead of paying the full price, you just pay a copay or percentage of your drug’s cost. The insurance company then pays the rest.

All Medicare Part D 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.

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 out 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.

How does Part D of Medicare work?

There are 4 stages to a Part D drug plan:

Deductible phase: For most stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, you’ll pay 100% for medication costs until you reach the yearly deductible amount (if your plan has one). The standard deductible for 2022 is $480.

Initial coverage phase: After you’ve reached the deductible, you’ll enter the initial coverage phase, where you will pay the plan’s cost share for covered medications. For example, if your plan benefit includes a 25% coinsurance in this phase and you’re taking a medication that costs $400 a month, your out-of-pocket cost would be approximately $100 a month.

Coverage gap, also known as the “donut hole”: begins if you and your plan spend a combined $4,430 in 2022 as described above. While in the coverage gap, you’ll typically pay 25% of the plan’s cost for brand-name drugs and for generic drugs in 2022. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $7,050 in 2022.

Catastrophic coverage phase: Begins if your out-of-pocket costs reach $7,050 in 2022. During the catastrophic coverage phase, you’ll only pay a small coinsurance or copayment for covered prescription drugs for the remainder of the year.

Each plan will have its own drug list, or formulary, 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.

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 their co-payments on retail medications. There are various levels of qualification, and your subsidy level 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.

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. 

If you want to get Part D coverage, you must choose and enroll in a private Medicare prescription drug plan (PDP) or a Medicare Advantage Plan with drug coverage (MAPD). Enrollment is optional (though recommended to avoid incurring future penalties) and only allowed during approved enrollment periods. Typically, you should sign up for Part D when you first become eligible to enroll in Medicare.

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

Learn About the “Donut Hole” Here