Medicare Part D, also called Medicare drug coverage or stand-alone Prescription Drug Plans, are an option for beneficiaries to receive drug coverage. Original Medicare does not cover most prescription drugs, but beneficiaries can choose to enroll in a Part D plan that will.
Unlike Original Medicare, Part D plans are offered through private insurers that may restrict the member to certain pharmacies and have different coverage levels for medication. Some plans may have a drug deductible.
These different coverage levels are called tiers. Typically, lower tiers have smaller copayments or coinsurance. Each plan can determine how many tiers they have and which drugs are included in each tier. Below is an example of a common setup:
- Tier 1: Preferred Generics
- Tier 2: Generics
- Tier 3: Preferred Brand
- Tier 4: Non-preferred
- Tier 5: Specialty
If your healthcare provider wants to prescribe a new medication, you may ask them to check your formulary before sending the prescription to the pharmacy. If there is a lower-cost alternative available, ask them if it may be an option for you. This may help you avoid issues or high costs at the pharmacy.
The drug deductible is the amount that the member pays before full coverage is in effect. You may be responsible for the full cost of the medication until the deductible is satisfied. Certain medications, vaccines, and tiers may not be subject to the deductible. Check your plan’s Summary of Benefits for more information.
If you are enrolled in a Medicare Advantage Plan, you may not be able to enroll in a Part D plan, even if the Advantage plan does not include drug coverage If you have other drug coverage through an employer, union, or Veterans Administration (VA), you may not need a Part D plan.
By: Steven Thomas Smith
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