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Part D: Prescription Drug Coverage

Medicare has strict regulations surrounding these plans.

What is Part D: Prescription Drug Plans?
Prescription Drug Plans (PDPs) are offered by private insurance companies approved by Medicare. Your choices will vary depending on where you live.

You can get drug coverage with a standalone Part D plan or as part of a Medicare Advantage plan (Part C).

In order to enroll into a Part D plan, medicare beneficiaries must be enrolled in Part B.

Two Ways To gEt Part D
Option 1: You can get Medicare Part D coverage through a stand-alone Medicare Prescription Drug Plan if you’re enrolled in Original Medicare.

Option 2: If you’re enrolled in a Medicare Advantage plan, you can get this coverage through a plan that includes drug benefits, also known as a Medicare Advantage Prescription Drug Plan (MAPD).

Formularies & Drug Coverage
Every Medicare Prescription Drug Plan has a formulary — that is, a list of covered drugs. The formularies vary among plans.
Late Enrollment Penalty
Medicare Part D coverage is optional, but if you don’t enroll in Part D as soon as you’re eligible, you might pay a late-enrollment penalty if you enroll later.

The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($35.02 in 2018) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.

Coverage GAP

The coverage gap, commonly referred to ask “The Donut Hole” has several phases. The coverage gap is a temporary limit on what most Part D Prescription Drug Plans or Medicare Advantage Prescription Drug plans pay for prescription drug costs. While you’re in the coverage gap, you might pay higher costs for brand-name and generic drugs. Below we’ve described each phase:

Deductible phase: For most stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, you’ll pay 100% for medication costs until you reach the yearly deductible amount (if your plan has one). The standard deductible for 2018 is $405.

Initial coverage phase: After you’ve reached the deductible, you’ll enter the initial coverage phase, where you will pay the plan’s cost share for covered medications. For example, if your plan benefit includes a 25% coinsurance in this phase and you’re taking a medication that costs $400 a month, your out-of-pocket-cost would be approximately $100 a month.

Coverage gap, also known as the “donut hole”: begins if you and your plan spend a combined $3,750 in 2018 as described above. While in the coverage gap, you’ll typically pay 35% of the plan’s cost for brand-name drugs and 44% of the plan’s cost for generic drugs in 2018. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $5,000 in 2018.

Catastrophic coverage phase: Begins if your out-of-pocket costs reach $5,000 in 2018. During the catastrophic coverage phase, you’ll only pay a small coinsurance or copayment for covered prescription drugs for the remainder of the year.

Read more about the donut hole and whether or not it will affect you.

Tip

It can be a good idea to review your Medicare Prescription Drug Plan coverage every year, to see if your plan covers the medications you need now and may need in the upcoming year.

Frequently Asked Questions
How much is the Part D penalty?
2018

In 2018, Medicare recalculated Mrs. Martinez’s penalty using the 2018 base beneficiary premium ($35.02). So, Mrs. Martinez’s new monthly penalty in 2018 is 31% of $35.02 or $10.86 each month. Since the monthly penalty is always rounded to the nearest $0.10, she pays $10.90 each month in addition to her plan’s monthly premium.

Here’s the math:

.31 (31% penalty) × $35.02 (2018 base beneficiary premium) = $10.86

$10.86 rounded to the nearest $0.10 = $10.90

$10.90 = Mrs. Martinez’s monthly late enrollment penalty for 2018

How can Buffer Benefits help me with finding a Part D plan?
Our staff take into consideration all of your prescriptions, dosage amounts and even the pharmacy you shop at, to create a comprehensive comparison of standalone Prescription Drug Plans or Medicare plans that include prescriptions.

We offer a complimentary analysis for you to keep.

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