What Drugs Are Covered By Medicare Part D?
Medicare Part D is a voluntary prescription drug benefit for Medicare beneficiaries. Part D helps pay for prescriptions covered by Medicare.
Medicare Part D plans cover over 200 prescription drugs.
Medicare Part D covers most commonly prescribed medications, including name brands and generics.
Does Medicare Part D have a drug formulary?
Medicare Part D has a formulary that lists covered prescription drugs and their dosages. Some drugs may be prescribed for certain health conditions, but are not covered by Medicare Part D.
The formulary helps keep drug costs down by allowing Medicare Part D sponsors (who are private companies authorized by Medicare) to negotiate with pharmaceutical companies and set the prices of covered drugs.
Medicare Part D covers about 95 percent of the most commonly prescribed drugs. The Medicare Part D formulary also includes drugs that can be used as alternatives to the more expensive drugs on the market.
What are the types of Medicare Part D plans?
Part D plans are offered by private insurance companies approved by Medicare. Medicare beneficiaries can choose from different plan types, such as the following:
Original Medicare Plan (also known as a stand-alone Part D drug plan)
Medicare Advantage Plan (also known as a drug plan or Part C drug plan)
Medicare Cost Plan (also known as a private fee-for-service plan)
Private Fee-for-Service Plan
There are many different plan types. Each plan type offers different types of services, which may include, but are not limited to, the following:
You can also choose to get prescription drug coverage only. This is called a Medicare Advantage prescription drug plan.
Some Medicare Advantage plans provide Part A and Part B services as well as Part D. This is called a Medicare Advantage plan with “extra benefits.” These extra benefits help cover some of the costs of physician and hospital services not covered by Medicare.
Medicare Advantage Part D plans are designed to be integrated with Original Medicare. When you choose a Medicare Advantage Part D plan, you are choosing a plan that provides both Part A and Part B and Part D benefits.
How does Medicare Part D work?
Medicare drug plans use a formulary (list of covered drugs) to decide which prescription drugs will be covered. Each drug plan type has its own formulary, as do individual plans. The formulary describes what drugs are covered and at what level. A drug's tier level is based on how often the drug is used in a year.
The plan sponsor and government negotiate with drug companies to create plan formularies with lower prices than the average wholesale price (AWP). The AWP is the price for a drug that wholesalers pay for it. When you go to the pharmacy to fill a prescription, the pharmacy may charge you the AWP or the pharmacy may charge you what the plan is paying for the drug.
The government and plan sponsors pay for drugs covered by Medicare Part D. When you fill a prescription through a Medicare Part D plan, you will pay an additional sum of money that is either a low percentage of the cost of the drug or a set dollar amount. This is your cost-sharing amount. The amount you pay for your drugs depends on the type of Part D plan you are enrolled in.
If you have Medicare Part D drug coverage, you are responsible for paying your monthly premiums and the cost-sharing amounts for your prescription drugs. You must also pay your Medicare Part B premiums.
The Medicare Modernization Act of 2003 gives you the freedom to choose the Medicare Part D plan that is right for you. You can switch plans or plans can switch you at any time during the year. When you change plans, your prescriptions are covered under the new plan immediately.
What is the benefit period?
The benefit period is the time period for which the Medicare drug plan pays for your medications. Most plans have a calendar year benefit period, although some plans have a January-December benefit period.
It is important to know your plan's benefit period. This way, you can ensure that you receive all of your medications during the year.
What is the gap in coverage?
The gap in coverage is the time period when you are responsible for paying for your prescription drugs. It is the time period between your enrollment in a plan and your eligibility for Medicare's catastrophic coverage.
What is catastrophic coverage?
Catastrophic coverage is a type of coverage that will help pay for your prescription drugs once you have spent a certain amount of money on your medications. This amount is called the coverage gap. The catastrophic coverage limit is not the same for all Medicare Part D plans.
You can find out more about catastrophic coverage on the Medicare website.
How does a Medicare Part D plan work?
Medicare Part D plans must cover all medications in six “protected classes.” These protected classes are determined by the formulary. These protected classes are:
What is a tiered formulary?
A tiered formulary is a plan benefit that uses a drug's cost and usage rate to determine the drug's place in a formulary.