Medicare Drug Plan
Who Is Eligible?
The Medicare drug plan, also called Medicare Part D, is available to anyone enrolled in Medicare Part A (the hospital coverage portion), and Part B (the medical coverage portion). Even if you are covered by another plan, you can switch to Medicare (if you are eligible), or Medicare will help you and your employer (if you have one) improve your drug coverage. If you do not join when you first become eligible, you may have to pay a fee if you decide to join later.
What Does It Cover?
The drug plan covers prescription drugs—both brand-name and generic, although you still have to pay part of the cost. Private insurance plans administer the Medicare prescription drug program. These plans must issue a list of drugs they will pay for, but they can change that list as long as they warn you that a drug will be dropped at least 60 days in advance. Plans will frequently not cover brand-name drugs for which less expensive alternatives exist. Your doctor can write a letter appealing these decisions on your behalf if needed.
What Does It Cost?
The costs of the drug plan will depend on different things—the medications you use, the plan you choose, and whether you go to a pharmacy in your plan’s network. Here are some costs you can expect to pay:
- Monthly premium—This is the monthly fee that drug plans charge.
- Yearly deductible—This is the amount of money you must pay for your prescriptions before your plan begins to pay.
- Copayments or coinsurance—This is the amount you pay at the pharmacy for your covered prescriptions after the deductible.
- Coverage gap—Most drug plans have a coverage gap. After you and your drug plan have spent a certain amount of money for your covered medications, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit.
- Catastrophic coverage—Once you have spent up to your plan’s out-of-pocket limit for covered drugs (this is your "coverage gap"), you only pay a small coinsurance amount or copayment for the drug for the rest of the year.
What If I Am Covered by Another Plan?
Your employer must tell you whether the company plan is generally as good as Medicare's. If it isn't, you may be able to keep your current plan and join a Medicare plan, or drop your current plan completely and replace it with Medicare's. If you decide to stay with your current plan for now but drop it for Medcare's later, you may have to pay a penalty. If, however, the plan you have now is as good as Medicare's, you can keep it until you are no longer covered (eg, retirement, layoff) and then join a Medicare plan within 63 days and pay no penalty.
How Should I Make My Decision?
By answering a few questions you should be able to choose a plan that works best for you.
- What drugs are you taking now? Does the Medicare plan you’re considering currently cover most of the costs for those drugs? (Bear in mind that coverage for specific drugs can change, or be withdrawn at any time.) It helps to make a list of all your medications and compare costs (and it's always a good idea to carry a list of your medications with you in case of emergency).
- Does the pharmacy you use most often carry the drugs covered by the plan? Here, your pharmacist can be of considerable help in choosing the right plan.
- How much can you realistically afford to spend on a plan each month and still save money over the course of the year?
- Do you have all the information about other insurance coverage you have?
- Is the plan you are considering flexible enough to change with your health needs in the future?
What If I Can't Afford Any Plan?
People with limited income and resources may be able to get extra help paying for the drug plan's monthly fee, yearly deductibles, and co-payments. The Medicare website has more information on how to obtain financial assistance.
Where Can I See the Plans?
The Department of Health and Human Services provides lists of plans available in all states, at http://www.medicare.gov/medicarereform/map.asp. Or you may contact your local Social Decurity office. In addition, local chapters of organizations advocating for the elderly community will have information on various Medicare drug plans.
How to Enroll
If you are already a Medicare beneficiary, the Social Security Administration ( http://www. ssa.gov) should have sent you a letter encouraging you to enroll and outlining your drug plan options. They generally contact eligible persons a few months before their 65th birthday. If you did not receive a letter, need more information about how to enroll, or have any questions about Medicare benefits, call your local Social Security office or your State Health Insurance Assistance Program (SHIP). Every state has a SHIP.
To enroll in a Medicare drug plan online, go to http://www.medicare.gov. You can also obtain prescription drug coverage and the rest of your Medicare coverage through a Medicare Advantage or other health plan, such as an HMO or PPO.
Social Security Online, US Social Security Administration
United States Administration on Aging
United States Department of Health and Human Services
United States Department of Health and Human Services. Extra help for people with limited income and resources. Medicare website. Available at: http://www.medicare.gov/medicarereform/help.asp. Accessed April 3, 2006.
United States Department of Health and Human Services. Medicare and You: 2010. Medicare website. Available at: http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf. Accessed November 29, 2009.
Last reviewed November 2009 by ]]>Brian Randall, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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