Medicare Part D
What is Medicare Part D?
Medicare Part D is a plan created by the federal government to help Medicare patients lower their prescription-drug costs. The plan is provided by private insurance companies, and is administered by Medicare.
What is Covered Under Medicare Part D?
Prescription drugs, biological products, insulin and certain vaccines are covered under Part D. Over-the counter drugs are not covered.
Who is Eligible for Medicare Part D Coverage?
Patients who are entitled to benefits under Medicare Part A and/or are enrolled in Medicare Part B.
How do Patients Enroll?
Patients who need to obtain outpatient prescription-drug coverage may join by:
- Enrolling in a Prescription Drug Plan (PDP) offered by a private insurance entity.
- Enrolling in a Medicare Advantage (MA) plan that offers both prescription-drug and other Medicare Services, also known as Medicare Part C. (Medicare Advantage Drug Coverage (Part C) Overview).
- How to Join a Medicare Drug Plan
Other links for Patients:
- Compare Medicare Prescription Drug Plans Side by Side
- Filling Prescriptions Before Receiving an Insurance Card in the Mail
How does Medicare Part D Work Within Medicaid?
Most Medicare drug plans have a coverage gap, often referred to as the "donut hole." This gap is the delta between the initial prescription-drug coverage limit and the catastrophic coverage threshold. Medicare Part D plans were created to assist patients who fall in that gap. (Costs in the Part D Coverage Gap)
The Patient Protection and Affordable Care Act of 2010 gradually decreases that coverage gap over the next few years. On the current schedule, it is set to gradually decrease to twenty-five percent in 2020 by using a combination of discounts from manufacturers and increasing the amount of generic prescriptions offered on the Medicare drug plans.
How are Prescriptions Affected by Medicare Part D?
Many plans under Part D place drugs in "tiers." Tier 1 consists of the lowest-cost drugs available to the patient.
In addition:
- Some plans may require a "prior authorization." This means that a prescriber must contact the plan and show a medically necessary reason as to why that particular drug is being prescribed in order to qualify for coverage.
- Plans may require a patient to try step therapy, which is a type of prior authorization. This requires a patient to try a less expensive drug proven effective for most people with the patient's condition prior to "stepping up" to a more expensive drug.
- Plans are required to cover at least two drugs in each class of drugs used to treat the same medical condition.
What Role do Pharmacies Play?
Plans contract with multiple pharmacies to create a "network." Any pharmacy willing to work within a plan’s terms and conditions, may join that network. The plan may refuse to cover a prescription if a patient fills that prescription outside of the plan’s pharmacy network. Plans may have a list of prescription drugs that are not covered.
Patients may expect their pharmacist to answer questions regarding their Medicare Part D coverage. For example, a pharmacist may be required to inform a patient that a drug is not covered by their plan. If this happens, patients often request a written explanation from the plan provider explaining why a specific drug is not covered. (Medicare Appeals and Grievances)
It is important to note that Medicare Part D is constantly evolving, and pharmacists should stay informed regarding the most recent changes.
Federal Resources:
There are numerous online resources available to the healthcare provider seeking information about Medicare Part D. These include federal websites such as:
- Medicare Eligibility and Enrollment
- Drug Plan Coverage Rules (Prior Authorization, Quantity Limits, Step Therapy, and Vaccine Coverage under Parts B and D)
- How Medicare Prescription-Drug Plans and Medicare Advantage Plans with Coverage Use Pharmacies, Formularies, and Common Coverage Rules