Part D

As we get older, we often take more daily medications to prevent conditions from worsening, such as cholesterol and high blood pressure. Unfortunately, Original Medicare (Part A and Part B) does not cover prescription medications. If you rely on medication and want to avoid high costs at the pharmacy, a Part D prescription drug plan may be right for you.

What is Part D?

Medicare Part D, offered separately through Medicare, encompasses prescription drug plans. These plans work by creating a list of covered prescription drugs. Both generic and name-brand drugs are included in this list. Copayments at the pharmacy are determined based on your level of monthly premiums and which tier the drug falls into. Generic drugs are sorted into a lower tier, requiring a lower payment at the pharmacy. Brand-name, non-preferred, and specialty prescription drugs are in higher tiers requiring higher copayments.

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What drugs are covered?

Every plan has its own formulary, which is a list of covered prescription drugs. While the plan can choose which drugs it covers, each is required to cover at least two drugs in the most commonly prescribed classes of drugs. Every therapeutic category is included. In six categories, plans cover most or all drugs. These are for antidepressants, antipsychotics, anticonvulsants, antiretrovirals, immunosuppressants, and anticancer.

What if my prescription is not covered?

All plans have a procedure in place for when a necessary drug is not covered. If you are prescribed a medication that is not on your plan’s formulary and cannot be substituted with a drug on the formulary, you can request an exception. You and your prescriber will need to request the exception. This procedure can also be used if you need a prescription in higher quantities than are supported by the plan.

What are the costs of Part D?

For your Part D plan, you will pay a monthly premium as well as copayments for each prescription when you get a refill at the pharmacy. There is also an out-of-pocket deductible, after which point you will owe 20% of the drug’s cost plus the dispensing fee at the pharmacy. If you reach the “coverage gap” of an exceedingly high out-of-pocket limit, you will cross over into “catastrophic coverage” and pay only small copayments for the remainder of the year.

For all of your Medicare questions, look to Swisher Insurance for clarity.