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Medicare Part D


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Medicare offers prescription drug coverage to everyone with Medicare. If you decide not to join a Medicare Prescription Drug Plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, or you don’t get Extra Help, you’ll likely pay a late enrollment penalty.

 

To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered.

 

2 ways to get drug coverage

 

1. Medicare Prescription Drug Plan (Part D). These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

 

2. Medicare Advantage Plan (Part C) (like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance)and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.

 

Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.

 

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 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 co-payment.

 

Medicare Prescription Drug Plans may have these 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.

 

If you or your prescriber believe that one of these coverage rules should be waived, you can ask your plan for an exception.

 

Part D vaccine coverage

 

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

 

Drugs you get in hospital outpatient settings

 

In most cases, the prescription drugs you get in a hospital outpatient setting, like an emergency department or during observation services, aren’t covered by Part B (these are sometimes called “self-administered drugs” that you would normally take on your own). Your Medicare drug plan may cover these drugs under certain circumstances.

 

You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Or, if you get a bill for self-administered drugs you got in a doctor’s office, call your Medicare drug plan for more information.

 

 

   

 

Complete Medicare information at the official U.S. government Medicare site

 

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