Prescription Drug Plans (Medicare Part D)
Prescription Drug Plan Basics
Medicare Parts A & B (Original Medicare) does not cover the cost of outpatient prescription drugs. To help fill this void, Medicare Part D, also known as Prescription Drug Plans, was created on January 1, 2006. The program is designed to help Medicare beneficiaries pay for the cost of outpatient prescription drugs.
What Part D covers
Medicare Part D is made up of many different kinds of drug plans that are provided by private companies. Each of these various plans covers its own list of drugs which is also called a formulary. The cost of a particular drug plan depends on whether or not you use a pharmacy in your plan’s network, and which types of drugs are included in the plan.
How to Enroll
There are two primary ways you can receive prescription drug coverage—with Original Medicare and Medicare Part D or a Medicare Advantage plan that includes prescription drug coverage. Because those are the only two options, it is generally not possible to be enrolled in a Prescription Drug Plan and a Medicare Advantage plan simultaneously. It’s important to note that prescription drug coverage is not mandatory; however, you may be assessed a penalty if you wait 63 or more days after your Initial Enrollment Period ends.
When to Enroll
There are specific times that you are able to enroll in a Prescription Drug Plan:
While it is possible to enroll in Medicare Part D even outside of the timeframes above, you will likely have to pay a late-enrollment penalty if you went without creditable coverage for too long, so it’s important to plan ahead.
Medicare Part D Costs
Medicare Part D plans typically charge a monthly premium. While the total premium varies by plan, the 2020 Part D base beneficiary premium is $32.74 according to Centers for Medicare & Medicaid Services. Most people, however, opt for additional coverage, and the overall average Part D premium is $47.59. That being said, there are significant variations in the actual premiums people pay for Medicare Part D since there are income-related surcharges and subsidies based on your income level. This is an example of the most basic model for Medicare Part D costs:
Step 1: Deductible
As with all deductibles, you are responsible for this initial fee, which varies and is set by the specific plan. The government sets a maximum deductible for Medicare plans that cover prescription drugs, which may change each year. Some plans may not have a deductible.
Step 2: Co-pay/Co-insurance
You will need to pay a certain amount for each prescription that is filled, after you have paid your plan deductible (if there is a deductible). A copayment is a fixed cost, for example, a $25 copay each time you fill a prescription. Coinsurance is usually a percentage, such as when you owe a 15% coinsurance for covered medications, after your plan has paid its specified amount.
Step 3: The Coverage Gap, aka “Donut Hole”
After Step 2 (initial coverage) limit is met, beneficiaries will cover 37 percent of generic drug out-of-pocket costs and 25 percent of brand-name drug out-of-pocket costs.
This is where things get a little more complicated. Once you have spent $4,240* on covered drugs (in 2020—it changes each year), you may enter the coverage gap, sometimes colloquially called the “Donut Hole”. This is a temporary increase in your out-of-pocket prescription drug expenses. Once you have paid up to $6,350* (again, in 2020), you’re out of the coverage gap.
*According to medicare.gov.
Step 4: Catastrophic Coverage
Once you have exited the coverage gap referenced above, Medicare plans begin what is known as Catastrophic Coverage—a period in which you pay only a small copayment or coinsurance for prescription drugs for the remainder of the year. It greatly reduces the cost of such medications (beneficiaries pay 5 percent). Of course, out-of-pocket totals reset at the end of each year.
Mayberry Advisors representatives can walk you through each of these details and provide you with assistance that is personalized for your needs.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048), to get information on all of your options.
Outside the Medicare Annual Enrollment Period, beneficiaries may enroll in a Medicare Advantage plan only if they meet certain criteria. A licensed insurance agent can help determine if you are eligible.
Not all plans offer all of these benefits. Availability of benefits and plans varies by carrier and location. Deductibles, copays, coinsurance, limitations, and exclusions may apply.
The purpose of this communication is the solicitation of insurance. Callers will be directed to a licensed insurance agent with Integriant Ventures Insurance and/or a third-party-partner who can provide more information about Medicare Advantage Plans offered by one or several Medicare-contracted carrier(s). Integriant Ventures Insurance Solutions and the licensed sales agents that may call you are not connected with or endorsed by the U.S. Government or the federal Medicare program.
Plan availability varies by region and state.