Part D Medicare Insurance

What is Medicare Part D?:

Part D of Medicare is your prescription drug coverage, which is offered to everyone with Medicare Parts A and/or B. This can be obtained by purchasing a stand-alone Prescription Drug Plan (PDP) alongside a Medicare Supplement Plan, or by enrolling in a Medicare Advantage plan with Perscription drug coverage (MAPD). If you decide not to join a Medicare part D when you’re first eligible and you do not have other creditable prescription drug coverage, or you do not get Extra Help, you’ll likely pay a late enrollment penalty

How Do I get Medicare Part D?

 

Traditional Medicare part D can be obtained in two ways; Stand alone PDPs, and MAPDs. Stand alone PDPs can be applied for during a beneficiary's Initial Enrollment Period, which is the three months before, the month of, and three months after turning 65 or joining part B for the first time. If you have recently left employer coverage, you may only have 63 days from the loss of coverage to enroll.

Medicare Advantage Plans (like an HMO or PPO) can be applied for during the same period as stand alone PDPs; the three months prior, the month of, and the three months after either turning 65 or obtaining part B. A beneficiary cannot purchase a stand alone PDP separate if the MAPD includes drug coverage. 

Both types of plans are called “Medicare drug plans.”  In either case you must live in the service area of the Medicare drug plan you want to join.

When Can I Join or change a Medicare Prescription Drug Plan?

  • Annual Enrollment Period - Between October 15 – December 7 each year, Medicare allows for anyone to join, switch, or drop their plan. The change will take effect on January 1 as long as the plan gets your request by December 7.

  • Initial Enrollment Period - When you’re first eligible for Medicare, you can join during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.

  • Disability Beneficiaries - If you get Medicare due to a disability, you can join during the 7-month period that begins 3 months before your 25th month of disability, includes your 25th month of disability, and ends 3 months after your 25th month of disability. You’ll have another chance to join that starts 3 months before the month you turn 65 ends 3 months after the month you turn 65.

  • Extra Help Beneficiaries - If you get Extra Help, you can join, switch or drop a Medicare drug plan anytime during the year.


You generally must stay enrolled for the calendar year. However, in certain situations, you may be able to join, switch, or drop Medicare drug plans at other times:

 

  • If you move out of your plan’s service area

  • If you lose other creditable prescription drug coverage

  • If you live in an institution (like a nursing home)


How do I join a Medicare part D?:

 

When you join a Medicare plan, you’ll give your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
If your Medicare Advantage Plan includes prescription drug coverage and you join a Medicare Prescription Drug Plan, you’ll be dis-enrolled from your Medicare Advantage Plan and returned to Original Medicare

What Drugs are Covered under part D?

Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Tiers are ranked 1-5 Drugs in each tier have a different cost.

For example, a drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.


 Do I pay more for part D based on Income?


A small group—fewer than 5% of all people with Medicare—may pay a higher monthly premium for Part D coverage based on their income. This includes Part D coverage you get from a Medicare Prescription Drug Plan, or a Medicare Advantage Plan or Medicare Cost Plan that includes Medicare drug coverage.

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain limit, you’ll pay an extra amount in addition to your plan premium. Usually, the extra amount will be deducted from your Social Security check.

 
Are there limitations with my Part D?


Medicare drug plans may have the following coverage rules:

Prior authorization - You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.

Quantity limits - Limits on how much medication you can get at a time.

Step therapy - You must try one or more similar, lower cost drugs before the plan will

cover the prescribed drug.

 
Does Part D cover Vaccines?


Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

For more specifics, give us a call or contact the plan for its current formulary.

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NJ Life and Health Insurance Group, LLC is not affiliated with or endorsed by the Social Security Administration or the Federal Medicare Program