What is Medicare Part D Coverage?

Medicare Part D is an optional plan that you can add to your existing Medicare plan that covers prescription drugs. Part D covers a wide array of medicine and even covers prescriptions for ailments such as cancer and HIV/AIDS. Different plans have different formularies, and each formulary comes with its own categorization for prescriptions.

Policyholders will have a list of both brand-name medicine and generic brands. If you are considering a Part D drug plan, be sure to go over the list of medicine you may need to ensure you are getting the most cost-effective plan.

Those who suffer from an opioid use disorder can also get coverage for treatments. For instance, medicine such as methadone and buprenorphine can be covered for pain. Methadone is often used to help those with this disorder who are inpatients in a hospital. Medicare Part A and Part B can cover these medicines when it is used through an opioid treatment program.

Additionally, those who require insulin for ailments such as diabetes could save money on their insulin. Depending upon the plan and the available savings, policyholders could pay no more than $35 for a month’s supply. During open enrollment, be sure to discuss with your agent from Golden Plan Choice how you can save money on your drug plan and what prescriptions may be covered.

What Are Formularies And Medical Exceptions?

A formulary is a particular plan’s list of prescriptions that are covered. When a health care provider prescribes medication, they often fall under a particular class and category. Each formulary includes at least two medications from the most common classes. Therefore, most people will be able to find the drug they take on one of Medicare’s lists of covered medications.

If your particular medication is not on a list, there is usually an alternative that most people are able to take. If for some reason, a health care provider deems it necessary that their patient take a specific drug that is not on the list of covered medication, there are exceptions.

Exceptions must be formally requested and sent in for approval. An exception is a drug plan’s decision to cover a particular medication. There is a formulary exception and a tiering exception. A formulary exception is a drug plan’s ruling on a specific medicine that is not on the drug list or to waive a coverage rule. A tiering exception is a plan’s ruling to lower the price that is on the non-preferred drug tier.

With each exception, the patient or the prescriber (doctor or other legal health care provider allowed to write prescriptions) must put in a request. This request must also include a written statement by the prescriber stating why this exception is needed.

Changes that Could Occur to Drug Plans

There are times that drug plans could cover a particular medicine, and then the medicine’s cost could change, or it is no longer included on the list. There can be several reasons for these changes. Many times, drug plan lists change due to drug therapy changes, new drugs being released, and new medical information. These circumstances can often affect the cost of these medications.

For instance, a plan could raise the copayment or coinsurance a policyholder pays for a particular drug. This can happen if the manufacturer raises its price. The price may also change if a plan offers a generic form of a particular drug, and a policyholder chooses to continue taking the brand-name drug.

If a medication is considered unsafe for people to take, as decided by the Food and Drug Administration (FDA), Medicare may remove the drug altogether. Plans may also change their requirements. If a drug does not meet these requirements, the drug could be subject to removal, or the cost of a particular drug could change to meet these requirements.

Policyholders that are affected by these changes will be notified of the change in a drug plan after the change has been made in one of two ways. Plans must notify their policyholders and give written notice at least thirty days prior to the effective date. Or they must also notify policyholders when a policyholder requests a refill and provide at least a month’s supply of medication under the original plan’s rule before the change.

Prescription Drug Tiers

To ensure costs stay low for people, each drug is categorized into a specific tier. Each plan categorizes medicine into different tiers. With each tier, there are different types of prescriptions, and they each have their own costs. The higher the tier, the more expensive the medication can be. Different drug plans will categorize their list of drugs differently. What may be found in one tier on one plan may be completely different on another plan. Typically, the lower tier will have the lowest prices.

For example, tier one could have the most generic prescription drugs. This tier may also have the lowest copayment. Tier two could have a slightly higher copayment. This list can typically have preferred prescriptions and brand-name prescriptions. Tier three will have a high copayment for non-preferred drugs and brand-name prescription drugs. A plan can also include a specialty tier. The specialty tier will often have the highest copayment with the most expensive prescription drugs.

If a patient’s health care provider deems it necessary for them to take a specific medication that is on the higher list, that patient could get an exception to pay a lower coinsurance or copayment.