MEDICARE PRESCRIPTION DRUG PLANS
If you are under Original Medicare or Original Medicare with a Supplement to Medicare Plan, you may need a stand alone prescription drug plan.
Part D was not part of Original Medicare. It wasn’t until 2003 that the Medicare Prescription Drug Improvement and Modernization Act became part of Medicare.In 2006, Part D provided subsidized access to prescription drug insurance coverage on a voluntary basis. You could voluntarily enroll in a stand alone prescription drug plan (PDP) or an integrated Medicare Advantage Plan that offers prescription drug coverage (MAPD).
If you have Original Medicare, you can enroll in a stand alone prescription drug plan. You would pay a monthly premium for the prescription drug plan and then have co-pays for each prescription drug. Some stand alone prescription drug plans have a deductible. In 2019, you could have up to a $415.00 deductible. Once you paid $415.00 out of pocket, the plan benefits would kick in. Medicare Advantage Plans may offer prescription drug coverage as part of the plan (MAPD). Some MAPD plans have a deductible, some do not. MAPD Plans may charge a monthly premium. Some do not. It is imperative to conduct research to determine which Medicare prescription drug plan suits your lifestyle.
Each prescription drug plan has a formulary (drug list). The formulary contains all the prescription drugs the plan offers. If you are enrolled in the prescription drug plan, you must choose drugs from the formulary, if you want the plan to pay for a portion of the drug.Each drug is placed on a tier. The tier acts as a pricing level for the drugs on the formulary. Some plans have a five tier formulary. Some plans have a four tier and others have a three tier. It is your responsibility to understand the number of tiers in your prescription drug plan, what the prices are per tier and what drugs are listed in the formulary.
A tier 1 is for preferred generic drugs. You will pay the least out of pocket expense for a tier 1 drug. Some prescription drug plans charge a $0.00 copay for a tier 1 drug. Some plans may charge $10.00 for a tier 1 drug. Each prescription drug plan has different copays. Do your due diligence! A tier 4 is usually designated as a brand drug tier. Brand drugs are newer drugs and they will cost you more. Copays for a brand drug can cost anywhere from $10.00 upwards to 33% for a 30 day supply. A tier 5 is for specialty drugs. Drugs you are unable to administer to yourself fall into this category. Injections you receive from your physician are usually a tier 5. Immuno-suppression injectables are a tier 5 drug. Certain cancer injectable drugs are a tier 5 drug. Certain injectable drugs for lupus or psorosis are tier 5 on most formulaires. Most prescription drug plans charge 33% of the medicare allowable cost for a tier 5 drug. Some may cost 28%.
You may not be on a MAPD and a stand alone prescription drug plan.
Formularies change during the calendar year. Each prescription drug plan, whether a stand alone plan or a MAPD must inform you of any drugs that are being removed from the formulary or being added on.
The plan must inform you of the change and give you sixty days notice. You must be able to discuss prescription drug changes with your physician in order to change prescriptions in a reasonable amount of time. The plan will give you a thirty-one day extension in order to assist you in the transition of your prescription drugs.