MEDICARE PART D | PRESCRIPTION DRUG COVERAGE
HELP WITH YOUR MEDICARE PART D PRESCRIPTION DRUG CHOICES
Medicare open enrollment periods happen between October and December each year, and are the period in which you can make various changes to aspects of your coverage. This is the period in which you can switch from Original Medicare to Medicare Advantage, or the other way around.
There are 2 main ways to get your Medicare coverage – Original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). Original Medicare doesn’t cover everything, so many people buy additional coverage, like a Medicare Prescription Drug Plan (Part D) or a supplemental Medigap Policy.
Medicare provides optional prescription drug coverage to anyone who has Medicare. However, it’s important to consider whether you’ll opt for Part D coverage upon first enrolling in Medicare. If you decide not to get Medicare drug coverage when you’re first eligible, more likely than not you’ll have to pay late enrollment penalties. And you’ll have to pay this penalty for as long as you have Part D prescription drug coverage.
ARE THERE EXCEPTIONS?
TWO EXCEPTIONS TO LATE ENROLLMENT PENALTIES ARE:
You have other creditable prescription drug coverage
You qualify for Extra Help
HOW TO ENROLL
To opt into Medicare Part D prescription drug coverage, you need to join a plan that’s Medicare-approved and that offers Medicare drug coverage. Plans vary by both cost and drugs covered. That’s why it’s extremely useful to consult with your pharmacist, who can review your medication history, help you anticipate which drugs you’ll need in the upcoming year, and assist you in assessing plans, co-pays — and ultimately finding the best plan for your unique needs.
AFTER SELECTING A PART D DRUG PLAN, THERE’S A PATH TO FOLLOW IN ORDER TO JOIN IT. YOU NEED TO:
- Complete a paper enrollment form
- Call the plan
- Call Medicare directly at 1-800-MEDICARE (1-800-633-4227)
- Use the Medicare Plan Finder Website to enroll
INFORMATION TO PROVIDE
When joining your Part D drug plan, provide them with your Medicare Number and the date your Part A and/or Part B coverage started. You can locate this information on your Medicare card.
CONSIDER YOUR OPTIONS
It’s important to consider all your prescription drug coverage options. If you have supplemental insurance, through the Department of Veterans Affairs, TRICARE, or insurance through your employer; consider what drugs those plans cover, how much you pay for them, and compare that with what you determine to be the best Part D plan for you. Again, drug coverage can change from year-to-year, so it’s important you review those changes and reassess what makes sense for your unique situation.
You should also be aware that enrolling in Part D may affect your Medicare Advantage coverage. In certain circumstances, your Part C plan will disenroll you and you’ll go back to Original Medicare coverage.
THAT HAPPENS WHEN BOTH OF THE FOLLOWING APPLY:
- The Medicare Advantage Plan you chose already covers prescription drug coverage
- You enroll in a Part D Medicare Prescription Drug Plan
CAN MY COVERAGE CHANGE?
During the year, your medical needs may have changed. You may now be taking medications you weren’t anticipating when you enrolled the previous year. Or perhaps a drug that was once covered by the plan you chose is no longer covered in the new year. The best time to switch prescription drug plans (Part D) is during the open enrollment period.
If you want to switch plans, you should do so as soon as possible to avoid delays in getting your prescriptions filled, and so that you have your new card as soon as your membership begins. If you switch plans, you’ll get a letter in the mail from your new Medicare drug plan, and that letter will inform you of when your coverage begins.
PLAY IT SAFE AND AVOID SCAMS: DON’T GIVE AWAY PERSONAL INFORMATION TO AN INSURANCE PROVIDER THAT CALLS YOU, UNLESS YOU’RE A MEMBER OF THAT PLAN.
DROPPING YOUR PART D PLAN
After reviewing plans, consulting with your pharmacist, and anticipating the year to come, you may find it’s in your best interest to forgo the optional Medicare Part D plan. The time to do this is during the Open Enrollment Period. When you drop your existing plan, it’s not required that you join a new plan.The change will go into effect on January 1 of the following year.
If you choose to drop your Medicare Part D (prescription drug plan) during the Open Enrollment period, you can do so by following one of these options:
- You can call Medicare at either 1-800-MEDICARE (1-800-633-4227)
- You can send a signed written notice to your plan by mail or fax telling them you want to disenroll
- You can submit an online request, if your plan offers this option
- You can call the plan directly and request they send you a dis-enrollment notice. When you receive the notice, you’ll need to complete, sign and send it back to the plan in order for your plan to be dropped
WHERE CAN I FIND MY PLANS CONTACT INFORMATION?
Typically, your plan’s contact information can be found on your membership card. Alternatively, you can find the contact information for your plan online through Medicare.gov. Open enrollment is so critical because you won’t be able to drop your plan outside that time frame unless you meet certain criteria.
After dropping a Part D plan, you can rejoin a plan in the future. However, it’s important to note that if you go 63 consecutive days or more without other creditable prescription drug coverage, you’ll have to wait for the next enrollment period to sign up for coverage and may experience late enrollment penalties.
WHAT IS COVERED BY MEDICARE PART D?
Every Medicare Part D drug plan has a unique list of covered drugs, commonly referred to as a formulary. Frequently, Medicare drug plans will place various drugs into “tiers” on their formularies, with drugs in each tier having a different cost.
For example, a medication that falls in a lower tier will typically cost less to the patient than a drug in a higher tier. In many cases, your prescriber might think you need a medication that’s in a higher tier. If that’s the case, it is possible for you or your doctor to ask your plan for an exception, qualifying you for a lower co-payment.
Within certain guidelines, it is possible that Medicare drug plans will make changes to their formularies during the year. If the change involves a drug you’re currently taking, you have rights.
BEFORE CHANGING THE TIER OF A DRUG YOU’RE PRESCRIBED, YOUR PLAN MUST DO ONE OF THESE:
- Notify you in writing at least 60 days before the date the change takes effect
- At the time you request a refill, provide both (1) notification of the change in writing; and (2) provide you with a 60-day supply of the medication under the same plan rules as before the change
MEDICARE SAFETY CHECKS
For certain drugs, Medicare Part D plans could add additional safety checks, and will alert your pharmacy for review prior to your prescription being filled. Safety alerts may happen in circumstances like:
- Potentially unsafe amounts of opioids. As your pharmacy, we may be asked to review your prescription with the prescriber to ensure the medications are safe.
- The first time you request prescription fills for opioids. In such cases, Part D plans may limit you to a 7-day supply or less if you haven’t recently taken opioids.
- If you use opioids and benzodiazepines at the same time.
- If for any reason your prescription can’t be filled as written, including the full amount on the prescription. In such cases, we will give you a notice explaining how you or the prescriber can get in touch with your plan to ask for determination of coverage. You can, of course, request an exception to your plan’s rules prior to going to the pharmacy, to ensure we can fill your prescription and that it covered by your plan.
Some plans may require a “prior authorization” to ensure certain drugs are used correctly and only when medically necessary. In other words, before your plan will cover certain medications, you will be required to demonstrate to the plan that you meet the criteria for you to have that particular drug.
OTHER RULES MIGHT INCLUDE:
- Quantity limits on certain medications
- Step therapy, in which you will be required to try a less expensive drug according to your plan’s formulary before certain medications will be covered
- Vaccination coverage for Part D: with the exception of those covered under Part B, Medicare Part D plans are required to cover all commercially available immunizations that are medically necessary (i.e., shingles)
- Drugs prescribed in hospital outpatient settings: You can request an exception should you or your prescriber believe that one of these coverage rules should be waived
USING YOUR PLAN FOR THE FIRST TIME
WHEN YOU USE A DRUG PLAN FOR THE FIRST TIME, YOU MUST BRING WITH YOU TO THE PHARMACY THREE ITEMS:
- Your red, white, and blue Medicare car
- Photo ID
- Your plan membership card
WHAT TO EXPECT
Within 2 weeks after your plan receives your finished application, you should receive a letter informing you they got your information. Within 5 weeks, you should receive a welcome package that will include your membership card. If you go to the pharmacy before your card arrives, you can use any of the following as proof of membership:
- The acknowledgement, confirmation, or welcome letter you received from the plan
- An enrollment confirmation number, along with the plan name and phone number
- A printable temporary card your plan offer from MyMedicare.gov
If you don’t have any of these, we might be able to get your drug plan information using your Medicare Number or the last 4 digits of your Social Security Number. If for whatever reason we can’t find your plan information, save your receipts and contact your plan directly to get refunds for any out-of-pocket costs you may incur.