Medicare-eligible seniors often wonder “does Medicare pay for prescriptions?” Perhaps you have a variety of medications that you need, and you want to know if Medicare will cover them once you switch. Will you have to change your medications? Switch to generic? How does it work?
In this article, we’re discussing prescriptions and Medicare coverage. If you have specific questions about your medications coverage through Medicare, give our Medicare consultants in Memphis a call today at (901) 460-7220.
Yes, Medicare Covers Prescriptions
Medicare offers prescription benefits for everyone enrolled in Medicare. This coverage is called Medicare Part D. You can read more about Part D here. There are a few ways to receive these prescription benefits through Medicare: Original Medicare (Parts A, B, and D with a supplement), through a standalone Part D plan, or through a Medicare Advantage plan.
What Do I Need to Know About Part D?
Like all things Medicare, Part D has its own vocabulary and other details that you may have never heard until now. In this section, we’ll discuss the essential details of Part D that you should know. Use this section if you are trying to learn more about Part D, decipher your coverage, or choose the right plan.
What Is a Formulary?
Each Medicare Part D plan has its own list of prescriptions which it covers called a “formulary.” Many Medicare prescription plans place medications in different tiers within formularies. If your medication is not included on the formulary or in a higher tier than you expected, you may request an exception, pay out-of-pocket, or file an appeal. For information on how to do this, call Delta Medicare Benefits Group. One of our dedicated Medicare consultants will help you understand where your prescription falls and how to potentially get it covered under your plan if it is not within your formulary.
In What Tier Is My Medication?
As mentioned, medications will be divided into different tiers within your plan’s formulary. Usually, Part D has four tiers:
Tier 1 - Preferred generic medication
Tier 2 - Non-preferred generic medication
Tier 3 - Preferred brand medication
Tier 4 and above - Non-preferred brand medication; expensive, specialty prescriptions
In most cases, the higher the tier classification, the more you will pay for your medication copays. When you enroll in your plan, a Delta Benefits Medicare consultant can help you review your formulary to ensure your medications are included and determine what your copays will be.
How Much Will Medicare Part D Cost Me?
There are a few costs that may be associated with Part D, depending on your specific situation:
Part D premiums
Deductibles and copays
Part D premiums vary based on your specific plan, your insurance provider, your location, the prescriptions you take, and your income from two years before the year you enroll in Part D. Our Medicare experts can help you determine your exact Part D premium.
People who make higher incomes may pay more for their premiums. This is called the Income Monthly Adjusted Amount (IRMAA).
Additionally, you may have to pay penalties if you delayed enrolling in Part D coverage and did not have creditable drug coverage (comparable medications coverage). You may be responsible for the Part D late-enrollment penalty if, at any time after your Initial Enrollment Period, there is a period of 63 consecutive days or more when you don't have Medicare drug coverage or other creditable prescription drug coverage. You’ll generally have to pay the penalty for as long as you have Medicare drug coverage.
The penalty you’ll have to pay will depend on how long you went without Part D or creditable drug coverage. Medicare uses a special equation based on the "national base beneficiary premium,” which is $33.37 in 2022. They take 1% of this amount and multiply it by the number of full, uncovered months you didn't have Part D or creditable coverage. The monthly Part D penalty you’re responsible for is then rounded to the nearest $0.10 and tacked onto your monthly Part D premium. Because Medicare utilizes the national base beneficiary premium to calculate the Part D penalty, your amount could change every year.
Part D deductibles and copays will also depend on your plan and insurance provider. Medicare sets a standard maximum deductible that serves as a guideline for all Medicare Part D insurance providers. For 2022, the maximum standard deductible is $480. No insurance provider can charge a deductible higher than the set standard for the year and some insurance companies may offer a lower deductible. Some plans even require no deductible. If your plan does require a deductible, you’re responsible for paying 100% of your prescription drug costs until you meet the deductible. However, there are exceptions to this rule – tier 1 and tier 2 prescriptions are generally exempt from the deductible.
Additional Part D costs may be associated with falling into the Medicare Donut Hole – most people will not enter the Donut Hole (also known as the Coverage Gap), but if you’re one of the few who will, you can read about it here.
Schedule a Free Consultation with Our Medicare Consultants
If you need to enroll in Part D or have questions regarding your coverage or medications, schedule an appointment with our Medicare advisors at (901) 460-7220. You may also fill out this convenient and secure online form, and we will reach out to you to set up an appointment.
We look forward to helping you navigate your Medicare benefits. For more information about our services and Medicare in general, check out our YouTube channel, where we post a Medicare or insurance-specific video every week.