What You Should Know About Your Medicare Part D Coverage

Medicare Part D

In their efforts to provide a standard level of prescription drug coverage, Medicare offers what is called Part D, which is a list of prescription drugs they cover. These drugs are called a formulary, and they are on different tiers of these formularies.


Medicare Prescription Drug Plans and Medicare Advantage Plans each have their own list of drugs that are covered. These plans include both brand-name prescription drugs and generic drug coverage. At least two drugs are included in the most prescribed categories and classes.


This ensures that people with medical conditions get the prescriptions they need. All Medicare plans must cover at least two drugs per category, but plans can opt for which drugs are covered by Part D.


The formulary might not include a specific drug but, in most cases, a similar drug should be available. An exception can be requested if a healthcare provider believes that none of the drugs on a plan’s formulary will work for a patient’s condition. In these cases, a specific drug can be allowed.


Read more below to learn about the changes that you should know about. It is important to be aware of these to avoid any surprises due to changes in coverage that you may not have been aware of.


Changes You Should Know About


Medicare drug plans can make changes to its drug list if it follows the guidelines set by Medicare. These changes are made since standards of care change, as new drugs are released, and when new medical information is made available.


If the Food and Drug Administration (FDA) removes a drug from their list of approved medications because they are unsafe or if the maker removes them from the market, the coverage may be deleted from the formularies. Brand-name drugs can also be replaced with generics for reasons such as a cost change. If a change is made, anyone with a prescription will receive notification of the change.


If a change involving a recipient’s prescription occurs, the plan must do one of the following:


  1. Give written notice to a recipient at least 30 days before the change takes place OR
  2. When a refill is requested, a written notice and a one-month supply must be provided under the same plan.


It should be noted that drug plans that offer Medicare prescription drug coverage (Part D) can remove a brand name drug from their formularies immediately and without prior notice. They may also replace them with generic drugs and change prices as well as coverage rules for all drugs. If a recipient is taking one of these drugs, they will receive a notice of these changes.


Changes may necessitate a change in the drug or the price you pay for it, although you may request an exception. Using the drugs on your plan’s formulary may save you considerable amounts of money instead of having to pay full price, unless you receive an exception.


Generic vs. Brand Name Prescriptions


The FDA considers generic drugs copies of brand-name drugs, and the same as those brand-name drugs in terms of:


  • Dosage
  • Strength
  • Safety
  • Route of Administration
  • Quality
  • Performance Characteristics
  • Intended U


The same active ingredients are used in generic drugs as are found in brand-name drugs. Before being approved for use by the FDA, generic drugs must be proven to work the same as brand-name prescription drugs. In some cases, however, there may be no generic drugs available for a brand name drug being prescribed. Interestingly, some generic drugs are better-known than the brand-name drug they serve as a substitute for. Fortunately, there may be another similar generic drug available that can serve as a substitute but works in the same way as the brand-name drug.


Regardless, anyone being prescribed a medication should discuss the possible use of generics with their physician.


Tiers


To lower costs, many plans offer prescription drug coverage that are on different tiers into their formularies. These tiers can be divided in different ways. These tiers cost different amounts. A drug in a lower tier will generally cost a patient less than a drug in a higher tier. Below is an example of a Medicare drug plan’s tiers, which might be different from yours.


Tier 1: Lowest copayment, most generic prescription drugs

Tier 2: Medium copayment, preferred, brand-name prescription drugs

Tier 3: Higher copayment, non-preferred, brand-name prescription drugs Specialty Tier. Highest copayment, high-cost prescription drugs


To lower costs, many plans offer prescription drug coverage that are on different tiers into their formularies. These tiers can be divided in different ways. These tiers cost different amounts. A drug in a lower tier will generally cost a patient less than a drug in a higher tier. Below is an example of a Medicare drug plan’s tiers, which might be different from yours.


In some cases, a more expensive drug on a higher tier may be prescribed, and the prescriber believes that the recipient needs that drug instead of a drug on a lower tier, an exception can be requested, and a lower copayment can be requested.


Please note that your plan may be different and coverage levels can also change. The above is only an example.


Summing Up Medicare Part D


Because Medicare Part D deals with Prescription Drugs, it is an important part of Medicare for most people. It is complicated, but don’t let that alarm you. You don’t need to know the ins-and-outs of Medicare to get the best coverage. After all, that is our job. We stay on top of all the changes to the drugs and formularies, so you don’t have to. If there is a change that affects you in the pipeline, we always will let you know well before it happens. So you can be prepared.


We hope that when it is time for you to choose your Part D coverage, you will let us coach you through the process. After all, our goal is to help people get the coverage they need. Please share this article if you felt it was informative!


And if you need help, simply tap the button below to get in contact and I will personally answer your questions.

How Can Your Current Medicare Plan Change Next Year?

By John Ellis • December 19, 2022
Many people are reluctant to change their Medicare Part D or Medicare Advantage plan coverage year-to-year. However, millions of Medicare beneficiaries will see significant changes in their Medicare costs and coverage. If you are staying with your current Medicare plan into next year, please be sure to review your plan’s Annual Notice of Change (ANOC) letter and use this list to help you look for important coverage changes that might impact your coverage next year. And remember, there are no health-related questions should you decide to change your Medicare Advantage plan or Medicare prescription drug plan (however, Medicare Advantage Special Needs Plans require that you meet the plan’s specific “need”). Your Medicare Plan May No Longer Be Offered Next Year Many folks are currently enrolled in a Medicare Advantage plan (MA or MAPD) that will no longer be available next year. We can help you determine what will be happening with the plans you are looking at, or the ones you are currently enrolled in. You May Be Automatically Reassigned to a Different Medicare Plan Next Year Every year, many people enrolled in Medicare Advantage and/or Part D Standalone plans are automatically "crosswalked" into another plan for next year. Normally, you will be notified if you are in this group but we are more than happy to help you know for sure. Your Medicare Plan May Change It's Name Sometimes, your Medicare plan (no matter what type it is) may be changing its name. Along with a name change, it could also have different features. Your Monthly Medicare Part D Premium May Be Increasing Many Medicare beneficiaries will see their monthly Medicare Part D premium increase 20% or more. Some people currently enrolled in a Part D plan will see their plan premium double next year. The good news is that there is a group of people that will see a premium decrease of 10% to 63% next year. Please keep in mind that in addition to lower-premium Part D plans, there may be low- or $0 premium Medicare Advantage plans (MAPDs) available in your area. Your Plan’s Initial Deductible May Increase Typically, the Medicare Part D deductible increases year-over-year. The exact amount can also depend on your situation. Your Medicare plan’s Initial Coverage Limit (ICL) may change Almost all stand-alone 2022 Medicare Part D plans use the standard Initial Coverage Limit (ICL), though some 2022 Medicare Advantage plans offer an ICL other than the standard — ranging higher and lower. Your drug plan’s ICL sets the boundary between your Medicare Part D plan’s Initial Coverage Phase and the Donut Hole or Coverage Gap. The ICL is measured by the total retail value of your prescription drug purchases. You can contact American Senior Benefits for detailed information on the Medicare Advantage plans that have an increased or decreased Initial Coverage Limit. Your Medicare Plan’s Cost-Sharing Can Vary Significantly Between “Preferred” and “Standard” Network Pharmacies Year-over-year, certain stand-alone Medicare prescription drug plans (PDPs) will use different cost-sharing for preferred vs. standard network pharmacies. As an example, your plan might have a co-payment of $0 for a Tier 1 medication at preferred network pharmacies and, for the same Tier 1 drug, a $5 co-pay when purchased at a standard network pharmacy. Your Medicare Advantage plan's Maximum Out-of-Pocket (MOOP) Limit May Change The Medicare Advantage plan MOOP threshold limits how much you will spend on co-payments and co-insurance for in-network, eligible Medicare Part A and Part B coverage. It can often change year-over-year for plans and it is important to be aware of these changes. The Bottom Line for Medicare Enrollees If you decide to stay with your current Medicare Part D or Medicare Advantage plan into next year– AND you understand how your Medicare plan is changing – you do not need to do anything – you will be automatically re-enrolled into your Medicare plan along with any changes your plan is making for the coming year. If your Medicare plan is being terminated in coming year and you are not merged or “crosswalked” to another Medicare plan, you may be without Medicare plan coverage on January 1st. We are always happy to clear up any confusion when it comes to these Medicare changes that you should be aware of, so please feel free to reach out whichever way is most preferable for you.

How to Compare Medicare Advantage Plans

By John Ellis • December 19, 2022
When it comes to Medicare Advantage plans, there are several factors to consider. Comparing these plans and knowing what to look at are crucial steps. Keep reading to learn more about Medicare Advantage plans, along with how they work and what you should consider when comparing the different plan options. A variety of benefits is offered by Medicare Advantage, which is also called Medicare Part C. Some people prefer the convenience offered by having all their drug and health benefits covered under one plan rather than enrolling in the stand-alone Medicare Part D coverage. Someone may also be looking for additional benefits that the original Medicare plan does not cover, like routine dental and vision coverage. Keep reading to learn more about Medicare Advantage plans, along with how they work, along with what should be considered when comparing the different plan options. What is a Medicare Advantage Plan? A Medicare Advantage plan is an alternative to Original Medicare, which includes Part A and Part B. Rather than having Medicare benefits provided through a government-run program, people who receive the coverage can obtain it through a Medicare Advantage plan, which is provided by private insurance companies that have been contracted with Medicare. For someone to be eligible to receive Medicare Part C, they must: Currently have Part A and Part B Medicare coverage Reside in the service area for the Medicare Advantage plan being considered Not be end-stage renal disease patients (there are a few exceptions) According to the law, all the Medicare Advantage plans are required to offer, at a minimum, the same amount of coverage as the original Medicare Part A and Part B Plans. However, some plans will cover other benefits, too, like dental, vision, hearing, prescription drugs, or specific health wellness programs. Unlike the original Medicare plans, if someone wants prescription drug benefits, which is provided by Medicare Part D, they should not enroll in a separate Medicare Prescription Drug Plan. A better option is to get the benefit from one of the Medicare Advantage Prescription Drug plans. Not all Medicare Advantage plans will include coverage for prescription drugs, so it is a good idea to double-check with the particular plan being considered. Tips for Comparing Medicare Advantage Plans Since Medicare Advantage plans are provided through any Medicare-approved private insurance company, the cost and the benefits may vary from one plan to another. Also, not all plans will be available in every location. When someone is comparing the Medicare Advantage plan options, there are several things they need to consider. Does the Monthly Premium Provide a Good Value? Some of the Medicare Advantage plans will have premiums that are $0; however, the individual must continue to pay their Medicare Part B premium, along with deductibles, coinsurance, and copayments, that the plan requires. What is the Annual Deductible for you? The annual deductible is another essential factor to consider. Is this something that you are comfortable paying? Are Any Additional Benefits Included? It is also important to consider if additional benefits are offered. This would include things like routine hearing, dental, vision, and other health or wellness plans. Also, find out if a prescription drug is included. Are the existing medications a person takes included with the plan’s formulary or the list of drugs that are covered? Is There a Provider Network Included If it does have a network, it is essential to find out if a person’s current doctors and their health care providers are included. What Is the Plan’s Star Rating? A star rating is one way to determine the performance of the Medicare Advantage plan. Every plan receives a rating of one to five stars. Five stars is the highest rating that a plan can receive. Medicare evaluates all plans based on the five-star rating system, and these scores are calculated yearly. Choosing the Right Medicare Plan for you Each person is unique. This means it is necessary to research each of the Medicare Advantage plan options available and how it works with a person’s budget and health needs. Remember, plan costs, provider networks, service areas, and benefits can all change from one year to another, so it is smart to review a person’s coverage regularly to ensure the plan still works. Take some time to shop around and choose a plan that will help you save the most money. I hope that you learned some valuable information from this article. Choosing a Medicare Advantage plan is a big deal, as you usually won’t be able to change it for up to a year. So you will have whatever coverage you choose for that period. If you find the plan doesn’t cover what you need, you will be stuck paying for it out of pocket. If you think you know someone who might benefit from this article, please share button it. If you'd like to talk about these things or anything else you might have questions about, please contact us whichever way is most comfortable for you.

What Are the Original Medicare Coverage Gaps?

By John Ellis • December 19, 2022
Original Medicare includes Part A and Part B coverage. It provides many medical and hospital services. While this is true, a person will also have to pay the cost-sharing amounts based on Medicare standards. There are some medical costs that Original Medicare will not cover. Coverage Gaps in Original Medicare One of the primary coverage gaps that occur in Original Medicare is coverage for prescription drugs. Some people do not realize that Medicare Part A and Part B coverage will not cover most of the prescription medications that are taken home. Usually, Medicare Part A will cover medications a person receives when they are an inpatient at a skilled nursing facility or a hospital. Sometimes, Medicare Part B will provide limited outpatient coverage for some of the prescriptions a person takes that they receive from the doctor’s office, such as chemotherapy or intravenous drugs. Keep reading below to see the costs that, in most cases, are not covered by Original Medicare. Usually, Original Medicare will not cover the following costs: Health coverage for individuals outside the country Routine vision services like contacts, glasses, or eye exams Nursing home care Routine hearing care services, including hearing aids Routine dental services like fillings, dentures, cleanings, or oral exams Routine foot care Cost Sharing with Original Medicare Even if you are receiving services covered by Medicare, there are limits to the coverage provided. It will be necessary for a person to pay out of their own pocket for these “gaps” in coverage. For example, with Medicare Part A, a person may receive full coverage for treatment from a skilled nursing facility for the initial 20 days of every benefit period. After that point, an individual must pay the daily coinsurance rate if the stay at the nursing facility extends from 21 up to 100 days. Past day 101, a person’s Medicare coverage is used, and a person must pay all related costs unless they have another type of coverage. Cost-sharing will usually include expenses such as: Part A deductible Part A coinsurance costs Part B copayment and coinsurance costs Part B deductible Medicare Supplement insurance plans may help offset some of these costs, but it is dependent on the plan that is purchased. It is also necessary to be aware that Original Medicare does not have any out-of-pocket limit during the year. There is no limit to the medical costs each year, even if the expenses result in hundreds of thousands of dollars in fees. What Are the Solutions to Medicare Coverage Gaps? There are a few options when someone is trying to avoid the coverage gaps seen with Medicare plans. For example, if a person wants to remain with their Original Medicare coverage by receive assistance with cost shaving along with coverage gaps, then Medicare Supplement insurance is a smart investment. Private insurance companies sell this, and the plans will work with Original Medicare plans to cover some out-of-pocket costs, such as deductibles and copayments. If you need assistance covering prescription drug costs, I can help you look into Medicare Part D coverage. This is a stand-alone plan that will help with medication costs. It is a good idea to enroll when someone is initially eligible for Part D, or someone may owe a late-enrollment penalty when a person signs up. Another viable option is to have Part A or Part B services provided through Medicare Advantage plans. This is an alternative method to receive the Original Medicare benefits, as these plans deliver both Part A and B benefits through a private insurance company that is Medicare-approved. Even if someone enrolls in a Medicare Advantage plan, they are still in the Medicare program. Some Medicare Advantage plans will also cover additional benefits, such as hearing services, dental care, vision care, prescription drugs, and specific wellness programs. An added benefit of Medicare Advantage plans is that they have a maximum out-of-pocket limit, which means there is a cap on the out-of-pocket costs. The limit could vary from one plan to the next. In many cases, Medicare will work with other insurance types, such as retiree insurance, employer-based coverage, and veteran benefits. The types of coverage may help and fill in some of the gaps present in Medicare insurance. Take time to consider all the factors mentioned here to find the right plan for a your needs and budget, as this is going to pay off in the long run. Don't leave your Medicare to Chance  Coverage gaps can be a scary thing, since they tend to surprise people who chose coverage without being fully informed. When you choose to work with my team, we take your needs and concerns as the first consideration. We show you plans that avoid coverage gaps and give you options based on what you need. If you feel this article helped you, please share it! And if you have any questions, you can contact me and I will personally answer any question you have.