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5 important things to know about Medicare’s Part D

Created date

October 23rd, 2012

With any health insurance, prescription coverage may seem like a fairly straightforward benefit. There are certainly advantages to these programs they may help lower your drug costs and give you better access to medicines that you need to stay healthy. But many people get hung up on the ins and outs of Medicare s Part D plan. For one thing, there is more than one way to get Part D benefits. Medicare itself does not provide a blanket Part D prescription plan. The benefit is administered through independent insurance companies. You can either choose a freestanding prescription plan (for which you will pay a separate premium), or you can get it as part of an insurance company s Medicare Advantage plan, which rolls Part A, Part B, and Part D into one plan with one premium. Knowing what s important about Part D may help you sort out your choices. 1 Part D is not mandatory. Even if you have Medicare Parts A and B, you do not have to sign up for Part D drug coverage, but think carefully before you defer it. Explore other benefit sources you may have, says Penny Folden, vice president of sales and service for Erickson Advantage, a Medicare Advantage plan exclusively for residents of Living communities. If your medications are covered at a lower cost from veterans benefits, for instance, you may want to opt out of Part D, but if you choose to enroll at a later time, you may have to pay a penalty fee or your premiums may be higher. 2 When checking if a drug is on a Part D formulary, look beyond the name. Certain categories of drugs, such as those used for cosmetic purposes, weight-loss aids, or prescription vitamins are not covered by Part D. Using the search tool on Medicare s website, you can look up the name of each of your medications. But even if you find your blood pressure medicine listed, your specific dose may not be covered, or there may be a monthly limit to how many pills can be dispensed. You also need to make sure your favorite pharmacy participates with Part D. Your doctor may be able to help you by evaluating your medication regimen. Your doctor may be able to do away with medicines that can be harmful or that have bothersome side effects, says Joel D. Posner, M.D., medical director at Grove, an Erickson Living community in Glen Mills, Pa. Ultimately, the goal is to simplify things taking something once a day is easier than taking it twice a day, for example. If you feel like you can t keep up with all of your medicines, having someone organize them for you every week can be helpful. 3 Your out-of-pocket expenses may rack up quickly. Everyone s heard about the so-called donut hole the coverage gap in which you must pay for your prescriptions (at a discount) once your total costs (including what the Part D pays) reach a certain preset amount. This can be a big expenditure if you haven t planned for it. When projecting what you ll have to pay, include premiums and co-pays. Those may vary depending upon how your plan is structured. Some use a tier system in which you pay different co-pays depending on where drugs fall on the tier tier 1 drugs are usually less than tiers 2 or 3. This system is not standardized across plans, however. A drug that is tier 1 (which may have no co-pay) on one plan may be classified as a tier 2 (which may have a high co-pay) on another plan. Some plans offer Step Therapy, which means you could be prescribed a less-expensive version of a drug, and then if it isn t effective, you would be stepped up to the more expensive drug without having to pay more. 4 Part D formularies change every year. Don t assume that if a medication is covered one year that it will be covered the next. Almost all formularies change annually because of new medications (and new generic forms of medications) coming on the market, current research on safety and effectiveness, and, of course, the cost of various medicines. Even if you have no intention of changing plans, check each of your medicines anyway. Even a single one that ends up costing a lot more could sap your budget. The annual enrollment period is the time to review your medicine list, Folden says. You can change to a plan that better suits your needs for the coming year. 5 Don t compromise your health to save a few bucks. I never prescribe a drug for someone without knowing what it s going to cost them, Posner says. And I spend a significant amount of time trying to get patients costs down many doctors do these days. Nevertheless, some people actually prefer a less-effective drug as long as it s inexpensive. But we have to be very careful about changing a medication that someone has been taking for a long time, especially if it works well. Comparing Part D plans is very important so you don t get caught in a position where you feel you have to make this kind of decision.