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Medicare Part D

Prescription Drug Coverage

Overview of Medicare Part D

Medicare Part D is prescription drug coverage. It is optional, in addition to Original Medicare.  If you are eligible for Part A and/or enrolled in Part B, you may choose to enroll in a Part D plan. Everyone eligible for Medicare Part A is automatically eligible for Medicare Part D. 

 

If you enroll in this coverage, you will be responsible for paying monthly premiums and a yearly deductible. Specific coverage options and costs depend on the plan and provider you choose. 

 

Original Medicare does not cover prescription coverage; therefore, you must purchase a Part D plan through a private insurance company as a standalone drug plan. This plan covers both generic and name-brand drugs.

 

You may add this plan to your Original Medicare coverage or receive it through your Medicare Advantage plan. ​


You might be eligible for lower or no-cost plans, including Medicaid if considered low-income.

 

It is essential to have prescription drug coverage even if you don’t take many prescription drugs; in many cases, as people get older, they tend to have an increased necessity for prescription drugs. Therefore, it is better to be covered should the need for prescription drugs arise. ​​​​​​​​​​​​​​

"​​​​​​​​​​​​​​​Medicare Part D (Medicare Prescription Drug Coverage or PDP) helps cover prescription drugs and may help lower your costs and protect against higher costs. Anyone with Medicare Part A and/or Part B can join a Medicare Prescription Drug Plan offered in their area. If you are in a Medicare Advantage Plan, your plan may also provide drug coverage."


Source: Center for Medicare and Medicaid Services (CMS)​​​

Important-Information for Part D

Enrollment Periods and Eligibility

​​​​When can you join a Medicare Part D Plan?

Enrollment starts between October 15 and December 7. Anyone can join, switch, or drop a Medicare Part D plan. The change will take effect on January 1, so long as the carrier receives your request by December 7.


You may join Part D within the seven-month period that begins three months before your birth month, your birth month when you turn 65, and ends three months after you turn 65.

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Suppose you are receiving Medicare due to a disability. In that case, you may join during the seven-month period that begins three months before the 25th month of your disability, which includes your 25th month of disability and ends three months after your 25th month. You can join three months before and after the month you turn 65.

How Medicare Part D Works

Understanding Formularies and Tiers

​When choosing a Medicare Part D plan, you can select one of five drug coverage lists known as formularies. A formulary is a list of prescription drugs that are grouped into specific categories or tiers. These tiers are:

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  • Tier 1: Low Copayment, Covers Preferred Generic Prescription Drugs

  • Tier 2: Slightly Higher Copayment, Covers Generic Drugs

  • Tier 3: A Bit Higher Copayment, Covers Preferred Brand Name Drugs

  • Tier 4: Higher Copayment, Covers Non-Preferred Drugs

  • Tier 5: Highest Copayment, Covers Specialty Drugs​​

Understanding Copayments

Filling Out Prescriptions

A copayment is a fixed amount you pay for a covered healthcare service after you’ve paid your yearly deductible. For example, you may have to pay $20 out-of-pocket for a specific drug. Preferred drugs cost slightly less than non-preferred drugs because your plan provider explicitly chooses them. You must select a non-preferred plan if you need prescriptions outside of this list.​

Important Medicare Part D Terms

You will face many unfamiliar terms when choosing a Medicare Part D plan. The list below includes important Medicare Part D terms you need to be aware of when searching for a plan:

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  • Part B vs. Part D Prior Authorization Required (B/D): Your Part B plan may cover this drug.

  • Prior Authorization (PA): This drug requires your doctor’s approval before your Part D plan covers it.

  • Step-Therapy (ST): If your condition is treatable by two different prescriptions, you may be required to test one possible drug before the other is covered.

  • Dispensing Limit (DL): This means that your plan will not allow for more than a 31-day supply of this drug.

  • Limited Access (LA): This drug is only available at certain pharmacies. Speak with your doctor to find out if this drug is available in your area.

  • Retail Only (RO): This prescription can only be filled in person at a pharmacy.

  • Retail and Mail (RM): This prescription may be filled at a retail pharmacy or through the mail.

  • Specialty Pharmacy Only (SP): This prescription must be filled out at a specialty pharmacy. Speak with your doctor to find one in your area.

Extra Help with Medicare Prescription Drug Costs

What is Extra Help?

Extra Help is a Medicare program for low-income and limited assets, also called the Low Income Subsidy (LIS). However, less than half of the people eligible for Extra Help sign up. So, if you need help paying Part D premiums, deductibles, and copays and think you might qualify, apply.

Do You Qualify for Extra Help?

To be eligible for help with drug costs, you must:
 

  • Live in the United States or the District of Columbia.

  • Qualify for Medicare Part A and/or be enrolled in Medicare Part B.

  • Single: If your annual income is $22,836, and your assets are less than $17,220 (2024).

  • Married: If your yearly income is $30,900, and your assets are less than $34,360 (2024).​

Need Assistance?

​TWhite Insurance will help you better understand your Medicare coverage options

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