Among all the Medicare plans, Medicare Part D is the latest addition to the Medicare Family, which was signed into law by President George W. Bush in 2003 and was introduced to the enrollees in January 2006. With the introduction of Medicare Part A, and Part B, qualifying Americans were having access to affordable hospitals and medical insurance but still, they were having no options for everyday prescription drug coverage. Thus, after forty years of Medicare, the government came into action to relieve the burden of prescription drug costs for seniors and the disabled. To get the right medications and the best deal, individuals should have complete knowledge about the Medicare Part D program.
With the rising drug prices, it is not at all surprising that very few people are able to afford and pay for their medications out of pocket. For all such people having prescription drug coverage through a Part D plan makes sense, as by paying a monthly premium and an annual deductible, people can keep their overall medicine costs down. However, before people can take advantage of the Part D plan, they should be eligible to sign-up for this plan. There are certain criteria that people need to meet to qualify for this program. Firstly, to be eligible for Part D people should be eligible for Medicare. Individuals should be U.S. citizens or legal residents with a green card, they should be of age 65 years or older, disabled individuals of less than 65 years of age also qualify for Part D as well as individuals suffering from ALS or kidney disease.
To apply for Medicare Part D, individuals need to first enroll in Part A, Part B, or both, as they do not have the option to apply for Part D alone. Individuals enrolled in a Medicare Advantage plan can avail prescription drug benefits by enrolling in Medicare Advantage Prescription Drug Plans that include the same coverage as Part D. Individuals at times may be eligible for Medicare but they may not be allowed to enroll in a Part D plan. This may happen if the individuals reside outside of the country or U.S. territories. They will only be eligible to sign up for Medicare Part D upon their return to the United States.
Medicare Part D Coverage
Medicare Part D plan just like any other prescription drug plan has a formulary, which is a list of preferred medications covered under a plan. The health insurance company offering Part D plan and the pharmaceutical companies manufacturing the drugs negotiate a deal and together they decide upon the list of medications that will be put on that plan’s formulary. Though the plan’s formulary does not cover every possible medication but covers a lot of drugs. Medicare Part D plans are required to cover two drugs from 148 different classes of drugs. All Medicare Part D plans have to cover the following six protected drug classes:
- Anticonvulsants, drugs that are used to prevent seizures
- Cancer drugs
- HIV/AIDS drugs
- Immunosuppressant, drugs that are used to protect transplanted organs
Most of the medications of these categories are included on every Medicare Part D plan formulary. Medicare required health insurance companies to include these drugs in their Part D plans. These are critical medications that avoiding can lead to serious health complications and even death.
Know about the Changes in Formulary
Individuals should be aware of the fact that Medicare Part D formulary doesn’t remain the same all throughout the year. Health insurance carriers can any time add or remove medications from the formulary. All the members of the plan who get affected due to the changes in the formulary are notified within 60 days. Individuals along with their doctors need to decide whether to change medications or request their plan to continue the medications. The other alternative people have is to pick another Part D plan that covers their medication. People are allowed to change to Part D plans during the Medicare Open Enrollment period that takes place between October 15 and December 7 every year.
Generic Vs Branded Medications
Medicare Part D plan formulary includes both generic and brand name drugs. It is often seen that people consider branded drugs as better compared to generics, but this is not necessarily true. Both generic and branded drugs are the same and comprise of the same active ingredients and come in the same doses. The major difference between the two is the manufacturer, who is making the drug. Generic drugs may cost as much as 85% less than their branded counterparts in some of the cases. Due to this, it is seen that the Medicare Part D plan recommends generic drugs in place of branded medications, as their intent is to save insured as well as insurance company money.
Options when Branded Drugs Are Medically Necessary
It is observed that in some cases a brand-name medication becomes necessary for an individual, even if it costs more. There might also be a situation when a branded medication will not be having generic versions available. In this situation, the Medicare Part D plan first recommends the insured to try another medication in the same drug class, generally a generic drug to save money. The plan may even recommend another class of medication that has generic options if it could prove cost-effective. However, people need to understand that they will pay more for a brand-name medication compared to a generic drug, but considering the fact that their health is more important, they should go for branded drugs when essential.
Drugs Excluded from Medicare Part D
People need to know that Medicare Part D plans are not all-inclusive, as Medicare has excluded certain medications from coverage. Some of the drugs that are not covered under Part D plan are:
- Cold & cough medications
- Fertility drugs
- Erectile or sexual dysfunction drugs
- Over-the-counter medications
- Drugs used for cosmetic reasons
- Vitamins and minerals with a few exceptions
Medicare Part D plans to cover some or all of these medications on their formularies as a supplemental benefit and to have access to these medications, people will need to pay more in premiums. It is completely up to individuals to decide whether it is worth to include those drugs at the added cost or not.