Without Medicare Part D, you might have to go without necessary medications. But before you panic, take a look at what the plan is and what you need to know about it.

Medicare is an invaluable program for many Americans. Without it, an untold number of people may go without health insurance, making it difficult, if not impossible, for them to access and afford medical care. Run by the federal government, it currently provides coverage for 44 million people. Its beneficiaries include people who receive Social Security Disability Insurance as well as individuals who suffer from End-Stage Renal Disease, a kidney disease that requires dialysis or a kidney transplant. The bulk of the people covered by Medicare, more than 83% of enrollees, are qualified due to their age, 65 years or older.

Are There Different Plans?

There are different plans within Medicare to help provide individuals with the types of coverage they need most. The two primary plans are Part A and Part B. Part A is hospital insurance that covers inpatient care at hospitals, skilled nursing care facilities, and hospice care facilities. Part B is medical insurance that covers medical treatment, diagnostics, and preventative care. There are two other primary plans, Part C or Medicare Advantage, also called Medigap, which includes supplemental plans to help individuals have more complete coverage, and Part D, which is the prescription drug coverage.

What is Part D?

While Parts A, B, and C are all essential parts of the comprehensive program, Part D is critical to providing medication to Medicare enrollees. Only added to the Medicare program in 2006, it’s one of the most-used parts of the program. It can also be one of the more challenging to navigate. There is so much information regarding coverage, medications paid for through the plan, how to enroll, who should enroll, and additional or supplemental plans, it can make your head spin. It can be hard to sort it all out yourself, so the specialists at Norgard Insurance Group have put together some information that can help. We want to make sure you sign up for the right plans so that you have what you need and so you don’t have to sacrifice your health by going without medication. Read on for what you need to know.

What Part D Covers

Part D helps Medicare patients pay for prescription medication. The drugs covered by this part of the plan include outpatient prescription drugs only. Both Medicare Part D and Medicare Advantage plans have separate lists of drugs covered by their plans. This is called a formulary. Each plan must give at least a standard level of coverage according to Medicare specifications, and the lists of drugs covered can vary based on the tiers and formularies set by Medicare. The drug lists can also change throughout the year and throughout the term of your Medicare enrollment. This can be due to updated drug therapies, new drugs available for prescription, or new medical information that becomes available regarding current drugs carried through the Medicare plans.

Both types of plans include brand-name prescription drugs as well as generic drugs. The formulary includes at least two types of drugs in the categories and classes used the most often by Medicare patients. This ensures everyone has access to the medications they need. If the formulary for your plan does not include the specific drug you need, there is usually a similar drug available. In some cases, a doctor or prescribing physician will not approve the medications Medicare has available through your plan. In these instances, there is an exception process you can go through to get the medicine you need.

Medicare Part D

Like Part C, Part D is optional coverage, but it is available to everyone enrolled in the Medicare Part A and Part B plans. While this part of the plan does include a large number of prescription medications, it does not cover all medications. You can find out if your particular medication is covered on the Medicare website.

It’s important to be careful when deciding whether or not to enroll in Part D. If you don’t enroll when your eligibility begins, you may be required to pay a late enrollment fee for as long as you have the plan. If you have prescription coverage through another source such as an employer, Department of Veterans Affairs, the Indian Health Service, a pension program, or a Medicare supplement plan, you may not need Part D. It’s essential that you consider what your current plan covers and what Medicare Part D covers so you can make an informed decision about carrying one or the other, or both.

What is Not Covered by Part D?

Part D does not cover over the counter medications such as ibuprofen, cough syrup, antihistamines, and antacids. You are responsible for the cost of over the counter medications. Additionally, Part D does not cover any medication administered in a doctor’s office or outpatient facility. These drugs fall under the Medicare Part B coverage instead. This can include an injection such as a flu shot or other vaccine, or IV medication given in a surgery center, pain management clinic, observation unit, or emergency room. It also includes drugs administered for treatment such as chemotherapy or dialysis. Part B also covers some self-injected medicines, including insulin, drugs used with durable medical equipment such as an infusion pump or a nebulizer, injectable osteoporosis drugs, blood clotting factors, and some injectable as well as oral medication for End-Stage Renal Disease. The Medicare website has additional information about what drugs are and aren’t covered by Part B.

How to Enroll in the Drug Coverage Plan

Eligibility for the drug plan is the same as for the other Medicare plans. You must either be age 65 or older, receive Social Security Insurance benefits, or suffer from End-Stage Renal Disease. To enroll in the Part D plan for prescription drugs covered by Medicare, you must also have Part A and Part B coverage.

Enrollment for Part D happens at the same time as Parts A and B. You can enroll during the Initial Enrollment Period, or IEP, which is the seven months surrounding your 65th birthday. This includes the three months before and the three months after you turn 65. Keep in mind – the plan goes into effect depending on when you enrolled. Waiting until the last minute can result in a delay in your coverage.

When you’re enrolling in your Medicare plan, it’s important that you are careful when deciding whether or not to enroll in Part D. Even if you don’t currently need prescription drug coverage, it may be beneficial to include it in your overall health insurance plan. If you don’t enroll during the IEP, you could be subject to late enrollment fees that you are responsible for every month for the life of your plan.

Some individuals have prescription drug insurance from other sources. These can include a current or former employer, a pension plan, a Medicare supplement plan, the Department of Veterans Affairs, or the Indian Health Service. Even if you are covered by another provider, you may still want to include Part D in your plan. Carefully evaluate what your current plan covers before you decide. Some plans may cover medications not covered by Medicare and vice versa. It can be beneficial to have both private insurance as well as Medicare Part D for a more complete prescription plan.

How to Use Your Medicare Drug Plan

Once you enroll in any of the Medicare drug plans, it’s time to fill your prescriptions. You can use most retail pharmacies for your prescriptions, but there are some restrictions. Here are the basic guidelines for where you can get your medications:

  • Network pharmacies – these are pharmacies that have an agreement to provide services and supplies for some Medicare plans at discounted prices. Some plans require you to use a network pharmacy. Check the details of your plan before having your doctor call in your prescription.
  • Preferred pharmacies – these pharmacies offered preferred pricing to Medicare members, which will save you money on any out-of-pocket expenses on your medications
  • Mail-order programs – you can choose to get your drugs shipped directly to you with some drug plans. It’s often more convenient for some members to have them delivered to their homes.
  • 2-3-month refill plan – if your plan provides the 2-3 month’s supply of prescription medication, you can take advantage of this to reduce the number of trips you make to the pharmacy

To fill a prescription for the first time, you will need to take your red, white, and blue Medicare card with you to your pharmacy. You will also need a photo ID and your plan membership card. Once you’re in the system, you shouldn’t need these items again at the same pharmacy.

What if you need to fill a prescription before you receive your Medicare card? Don’t worry – you can still get the medication you need. You can take your acknowledgment of enrollment paperwork, your enrollment confirmation, or your Medicare welcome letter as proof of coverage. If you don’t have any of these items available, your pharmacist may still be able to look up your coverage information using your Medicare number and the last four digits of your social security number.

Norgard Can Help You Sort Through the Information

There is a lot of information to keep track of when it comes to prescription drug coverage. This is true of private insurance plans, and it’s definitely true of the various Medicare plans available to help you pay for your prescriptions. It can be tempting to skip enrollment because you get overwhelmed trying to figure out what plan to choose. But don’t take the risk that you won’t be covered in the event you require prescription medication. It can cost you significant out-of-pocket expenses if you have to pay for these types of doctor-ordered drugs yourself.

The good news is, we can help. The team at Norgard Insurance Group knows all of the ins and outs of prescription drug coverage, both Medicare and private, and can help you sort through the information so you can rest assured you have the right plans in place so you get the medication you need when you need it. Contact us today for help choosing your Part D plans, supplemental plans, and any information regarding drug insurance you have questions about.