Everything You Need To Know About Medicare Part D Drug Plans

Michael T Braden, August 27, 202 MEDICARE PART D

Everything You Need To Know About Medicare Part D Prescription Drug Plans

WHAT IS COVERED UNDER MEDICARE PART D

At Braden Medicare Insurance, we want to share with you this "Everything You Need To Know About Medicare Part D Drug Plans." Medicare Part D plans are Insurance plans for your Prescription Medications, including vaccinations.  Private insurance companies offer these plans.

Each plan that offers prescription drug coverage under Medicare Part D must provide at least the standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies. (A formulary is a listing of all of the drugs/medications that a particular plan has available to its members.  All Medicare Part D Plans must have two drugs available in each category. 

Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of covered drugs, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary consists of at least two drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare Part D drug plans must cover at least two drugs per drug category, but they can choose which drugs to cover. The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.

NOTE: If you need assistance, please call your Medicare Broker. They will be happy to assist you. Also, make sure that any doctor who prescribes for you knows which Medicare Part D Drug Plan you are using. It makes it much easier for them to verify that the medications are already available in your plan's formulary.

A Medicare drug plan may make changes to its drug list during the year if it follows Medicare guidelines. Your plan may change its drug list during the year due to evolving therapies, new drugs, or newly available medical information.

Plans offering Medicare prescription drug coverage under Part D may immediately remove drugs from their formularies if the Food and Drug Administration (FDA) deems them unsafe or if their manufacturer withdraws them from the market. Plans that meet specific requirements can immediately remove brand-name drugs from their formularies and replace them with new generic drugs, or change the cost or coverage rules for brand-name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards.

For other changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:  

• Give you written notice at least 30 days before the date the change becomes effective.

• At the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change.

  
  
  
  

GENERIC PRESCRIPTION MEDICATIONS

The Food and Drug Administration (FDA) says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:  

• Dosage Form

• Safety

• Strength

• Route of Administration

• Quality

• Performance Characteristics

• Intended Use

  
  

Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug makers must demonstrate to the FDA that their product is bioequivalent to the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber about your generic drug coverage. To lower costs, many plans offering prescription drug coverage place drugs into five different “Tiers” on their formularies. Each plan can structure its tiers differently. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier. Here's an example of a Medicare drug plan's tiers (your plan’s tiers may be different):  

• Tier 1—lowest co-payment: most generic prescription drugs

• Tier 2—medium co-payment: preferred, brand-name prescription drugs

• Tier 3—higher co-payment: non-preferred, brand-name prescription drugs

• Specialty Tiers—highest co-payment: very high cost prescription drugs

MEDICATION THERAPY MANAGEMENT PROGRAMS

If you're in a Medicare drug plan and take medications for different medical conditions, you may be eligible for a free Medication Therapy Management (MTM) program. This program helps you and your doctor make sure that your medications are working to improve your health.

THROUGH THE MTM, HERE IS WHAT YOU WILL GET

• A comprehensive review of your medications and the reasons why you take them.

• A written summary of your medication review with your doctor or pharmacist.

• An action plan to help you make the best use of your medications (there will be space for you to take notes or write down any follow-up questions).

  
  

A PHARMACIST OR OTHER HEALTH PROFESSIONAL WILL REVIEW YOUR MEDICATIONS AND DISCUSS THEM WITH YOU

• Whether your medications have side effects

• If there might be interactions between the drugs you're taking

• Whether your costs can be lowered

• Other problems you’re having

  
  

It’s a good idea to schedule your medication review before your yearly wellness visit so you can discuss your action plan and medication list with your doctor. Bring your action plan and medication list to your visit, or whenever you speak with your doctors, pharmacists, and other healthcare providers. Also, take your medication list with you if you go to the hospital or emergency room. If you take many medications for more than one chronic health condition, contact your drug plan to see if you're eligible for a Medication Therapy Management program.    

USING YOUR MEDICARE PART D DRUG PLAN FOR THE 1ST TIME

BRING THESE WITH YOU TO THE PHARMACY

• Your Red, White, and Blue  Medicare Card.

• A photo ID (like a state driver’s license or passport).

• Your plan membership card.

HOW TO FILL A PRESCRIPTION WITH YOUR NEW CARD

If you go to the pharmacy before your drug plan card arrives, you can use any of these as proof of your drug plan enrollment:

• The acknowledgement, confirmation, or welcome letter you got from the plan.

• An enrollment confirmation number, the plan name, and the plan's phone number.

• A copy of your official Medicare card that you can print by logging in or by creating your own Account at www.medicare.gov

  
  
  
  

If you don't have any of these items, your pharmacist may be able to get your drug plan information. You'll need to provide your Medicare number or the last four digits of your Social Security Number. If your pharmacist can't access your drug plan information, you may have to pay for your prescriptions. If you do, save your receipts and contact your plan to get a refund.

YOU CAN USE THE AUTOMATIC RE-FILL MAIL-ORDER SERVICE FOR YOUR PRESCRIPTION MEDICATIONS

Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. In the past, some prescription drug plans didn’t ensure that customers still wanted or needed prescription drugs, creating waste and unnecessary costs for people with Medicare and Medicare Prescription Drug Coverage (also referred to as Medicare Part D). 

Now, plans must obtain your approval to deliver a prescription (new or refill) unless you request the refill or a new prescription. Some plans may request your authorization annually so they can send you new prescriptions without asking before each delivery. Other plans may ask you before each delivery. This policy won’t affect refill reminder programs where you go in person to pick up the prescription, and it won’t apply to long-term care pharmacies that give out and deliver prescription drugs. Giving your approval may be a change for you if you've always used mail-order and haven't had the opportunity to confirm that you still need refills.

Note: Be sure to provide your pharmacy with the best way to reach you so you don't miss refill confirmation calls or other communications.

Contact your plan if you get any unwanted prescription drugs through an automated delivery program.

You may be eligible for a refund for the amount you were charged. If you aren’t able to resolve the issue with the plan or wish to file a complaint, call 1-800-MEDICARE (1-800-633-4227).

If you have both Medicare and Medicaid or qualify for Extra Help, also bring with you any proof of your enrollment in Medicaid or proof that you do qualify for Extra Help. 

UNDERSTANDING NETWORK PHARMACIES, PREFERRED PHARMACIES, AND NON-NETWORK (RETAIL) PHARMACIES

Medicare drug plans have contracts with "Network Pharmacies." These pharmacies have agreed to provide members of specific Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies. In addition to retail pharmacies, your plan’s network might include preferred pharmacies, a mail-order program, or a retail pharmacy option that provides a 2- or 3-month supply.

PREFERRED PHARMACIES

Every Medicare Part D Plan has Preferred Pharmacies. These are the Pharmacies you always want to use, because they have the lowest prices for your Medications. Most Mail-Order Pharmacies are Preferred Pharmacies. If your plan has preferred pharmacies, you may save money on your out-of-pocket prescription drug costs (like a co-payment or coinsurance) at a preferred pharmacy because it has agreed with your plan to charge less.

OUT-OF-NETWORK OR STANDARD PHARMACIES

You do not want to use Standard or Out-of-Network Pharmacies at all, unless in an emergency. The reason is that you will typically pay 2-10 times more for your medications. Your Preferred Pharmacies are the ones that have contracts to give you the lowest prices, and the other pharmacies are just making as much money as they can at your expense.

MAIL-ORDER PHARMACIES

Almost every Medicare Part D Drug Plan offers a Mail-Order option. This can be very convenient. But be sure to check prices to see whether your Mail-Order Pharmacy is priced at the exact cost or lower than your plan's regular Preferred Pharmacies. Usually, they are close, but many Mail-Order plans, such as Cigna, charge substantially more if you use Mail Order. Be smart and do your research. But you can't beat the convenience of knowing your medications will be automatically delivered to your door every three months.

CHECK THE AMAZON PHARMACY IF YOU TAKE MULTIPLE MEDICATIONS THROUGHOUT THE DAY

If you are an AMAZON PRIME MEMBER, the Amazon Pharmacy has Preferred Pharmacy pricing with the majority of Medicare Part D Prescription Plans. And they will ship your medications in easy-to-see "Pill Packs" for each time of day, with your Medications already sorted for you. This is a Game Changer for many seniors.

LOOK INTO SEEING IF YOUR DOCTOR WILL PRESCRIBE A 2, 3, OR 6 MONTH PRESCRIPTION FOR YOUR MEDICATIONS

Some retail pharmacies may also offer 2-, 3-, or even 6-month supplies of medications. This is not only a time-saver but also a cost-saver.

CAN YOU FILL A PRESCRIPTION IF YOU DO NOT HAVE YOUR NEW MEDICARE PRESCRIPTION CARD YET?

Yes, if you go to the pharmacy before your drug plan card arrives, you can use any of these as proof of your drug plan enrollment:

• The acknowledgement, confirmation, or welcome letter you got from the plan.

• An enrollment confirmation number, the plan name, and the plan's phone number.

• A temporary card you may be able to print from the www.mymedicare.gov website. 

  
  

If you don't have any of these items, your pharmacist may be able to get your drug plan information. You'll need to provide your Medicare Number or the last four digits of your Social Security Number.

If your pharmacist can't get your drug plan information, you may have to pay some out-of-pocket costs for your prescriptions. If you do, save your receipts and contact your plan to get a refund.  

NOTE: If you call your Medicare Broker or your Medicare Part D Plan, they can usually email you a Temporary Prescription Card that you can use until either your new Card or a replacement card arrives.