Medicare Prescription Drug – Part D Coverage

Original Medicare is the U.S. government’s taxpayer-supported health insurance program that makes up the foundation of the full Medicare system. It provides hospital insurance and medical benefits to qualifying Americans. However, it does not cover most prescription drugs.

To get these benefits you will likely have to look to the private insurance marketplace. Medicare regulations allow private insurers to sell qualifying prescription drug plans to Medicare patients.

The primary benefit is called a Medicare prescription drug plan, better known as Medicare Part D. You will buy these benefits separately from Original Medicare. However, they will still integrate with your Original Medicare benefits.

Multiple major insurers in California offer Part D benefits, and each will offer extensive coverage for both your everyday and specialty prescription needs. With Part D coverage, you can substantially reduce your personal cost burden for the medications that you might need.

Part D benefits must meet certain standards as set by Medicare law. However, insurers do have leeway to determine the other benefits that they will provide.

• Your plan choices may be limited depending on the policies available in your area.
• All Medicare prescription drug plans will include a formulary of the drugs that they cover, and each will use different methods to set the costs of each prescription.
• You will have a copayment on most prescriptions. However, many of these will be nominal.
• Plans also have coverage phases—initial coverage, the donut hole and catastrophic coverage—that you encounter based on how much you are spending on prescriptions. Your drug costs might vary depending on where you are in the plan cycle.
• Most plans must give patients a choice of drugs. You can ask your doctor to appeal for coverage if your plan does not already cover a drug you need.
• To receive optimized coverage and the lowest costs, you should use a pharmacy within your plan’s network.

You must have Original Medicare before you can qualify for a Part D plan. However, if you still qualify for prescription benefits through another health plan, such as from your employer or military benefits, then you might be able to use both plans to lower the costs of your prescriptions further. The two plans will work together, though which one is the primary payer, or the secondary payer can vary.

There are two times when you can qualify to enroll in Part D coverage:

• The Medicare Initial Enrollment Period (IEP). This is a seven-month period that centers around your 65th birthday. It lasts from the first day of the month three months before your 65th birthday to the last day of the month three months after.
• Medicare Annual Enrollment. This period occurs each year from Oct. 15 – Dec. 7. During open enrollment, you can either buy a Part D plan or upgrade your Original Medicare to a Medicare Advantage plan that offers you prescription drug benefits.

In certain cases, you can enroll in Part D coverage if you qualify for a special enrollment period.