What You Need To Know About Medicare Part D
Medicare Part D provides specific benefits not covered under Medicare Part A or Part B. Learn about Part D, costs of Medicare Part D, how to enroll and other valuable information, including for individuals currently receiving or expecting to receive senior care and senior living services.
What Is Medicare Part D?
Medicare Part D provides prescription drug coverage for eligible individuals. If you have Medicare Part A, Part B or both, you are eligible for prescription drug benefits under Part D, regardless of your income or health. This is true even if you take several prescription medications or none at all when eligible to enroll in a Medicare Part D plan.
Enrolling in a Part D prescription drug plan is optional. However, Medicare Part D protects you against the high costs of prescription drugs in the future, even if you do not feel you need it when initially eligible to enroll.
Seniors receiving senior care services, residing in an assisted living facility, nursing home or residing in a senior independent living community often struggle with paying for prescription drugs. Medicare Part D helps with the cost of prescription drugs, potentially reducing some costs associated with improving and maintaining health and quality of life.
What Is The Cost Of Medicare Part D?
Medicare Part D requires eligible recipients to pay a yearly deductible. This is the amount that you pay for prescriptions prior to when the Medicare Part D plan starts paying its share of covered prescription drugs.
Most individuals pay a monthly premium. The amount varies from one Medicare Part D provider to the next and depends on factors such as if you are a recipient of Medicare Extra Help. Many Medicare Advantage Plans also include prescription drug coverage in specific plans.
Individuals above certain income levels often pay a surcharge for their Medicare Part D coverage, called a Part D income-related monthly adjustment amount (Part D – IRMAA). Medicare explains that your adjusted gross income from two years prior determines any Part D – IRMAA cost.
Late enrollment penalties also add to Medicare Part D costs for individuals who do not enroll when initially eligible, who then enroll at a later date. The exception is when an eligible person has other creditable prescription drug coverage or receives Medicare Extra Help.
What Does Medicare Part D Cover?
While Medicare Part D prescription drug plan covers many prescription medications, it is important that eligible recipients, family members and caregivers, including staff at senior care and senior living facilities understand that Part D does not cover all drugs. Medicare Part D eligibility does apply to an individual receiving senior care or senior living resources and services.
Once you choose a Medicare Part D plan, you receive a formulary from the provider. Each plan provider has its own list of covered prescription drugs. Plan recipients receive an updated formulary before the start of each new year.
The formulary also lists each covered drug by specific tiers. Each tier, ranging from least expensive, usually generic medications, to the next tier, including most brand-name or preferred drugs, to the highest tier, typically highest priced drugs or those not commonly prescribed, lists the co-pay for each drug.
Medicare Part D providers do not cover all prescription drugs and only cover others with “Prior authorization.” When a drug requires prior authorization, the prescribing physician submits a required form to the Part D provider, explaining why you need that specific drug.
Medicare Part D recipients have the option to appeal a decision regarding a drug not covered or a prior authorization rejection.
There is a temporary limit on what the prescription drug plan pays once an individual reaches the donut hole. What is the donut hole? It is the term describing the coverage gap between the initial coverage period and catastrophic coverage that some recipients reach after the individual and the Part D plan pays a specific amount for covered drugs. The amount often varies from one year to the next. For example, an individual that, along with their Part D plan, paid $3,750 for covered prescription drugs in 2018 entered the donut hole.
The amount paid for each prescription drug after reaching the coverage gap varies, depending upon whether the drug is generic or name brand and whether the Medicare Part D plan includes coverage once you enter the donut hole.
How Do I Enroll In Medicare Part D?
Seniors residing in independent or active living communities often have a coordinator or other on-site representative to help guide residents that have questions or need help enrolling in or selecting a Medicare Part D plan. Family members of individuals not capable of making decisions on their own, such as those residing in memory care, assisted living facilities or nursing homes often turn to the appropriate facility contact person to help enroll a loved one in the ideal Part D plan.
Individuals enrolling in Medicare Part D need to enroll at specific times. If enrolling for the first time, there are available enrollment options. The initial enrollment period (IEP) begins three months before and extends through three months after the month that you turn 65 years of age. The IEP requires that you do not have any other creditable prescription drug coverage and that you have not yet received Medicare.
You can also enroll in Medicare Part D during the annual open enrollment period, from October 15 through December 7 of each year. Part D coverage then begins on January 1 of the following year. The open enrollment period also allows individuals to change from a current Part D provider to another Medicare-approved Part D plan.
Circumstances sometimes occur that allows a person to enroll in Medicare Part D during a special enrollment period (SEP). One example is if you or a loved one moves into or out of a nursing home or certain other senior care facilities.
Medicare Part D offers prescription drug coverage, whether an eligible individual resides in an independent living community, in a nursing home, assisted living or other facility offering care and senior living resources for eligible seniors.