Medicare prescription medication coverage is available to anyone that is on Medicare. Those people who have limited income and resources, might be eligible to receive help to help them pay for their Medicare drug plan expenses.
You can join a Medicare drug plan when your Medicare first starts. You are first able to apply within three months before the month your Medicare begins and three months after it has started. If you apply before your Medicare starts then the plan will go into effect on the day your Medicare starts. If you apply after your Medicare has started, and assuming you apply within three months of your Medicare's effective date, the plan will start the first day of the month following the month when the application is submitted.
For those people who are disabled they can generally join three months before and three months after the 25th month of their disability benefits.
Between November 15 and December 31 of each year people on Medicare are given the opportunity to either join a Medicare prescription drug plan or change to a different plan. If you change plans or join a medication plan during this time, the coverage would be effective on the first day of the following year. There are special circumstances where a person may be able to join a plan at other times.
Some people may have a Medicare Supplement policy that already includes prescription coverage. The prescription coverage included with these Medicare Supplement plans may or may not be as good as the coverage required by Medicare in order to avoid paying penalties for not having signed up for a Medicare Part D prescription drug plan when it first became availble to that person. A person who has prescription coverage on their Medicare Supplement plan but did not sign up for a Medicare Part D prescription plan during the initial enrollment period might be facing a monetary penalty if they decide to drop the prescription coverage from their Medicare Supplement (or switching to a different Medicare Supplement that does not have prescription coverage) and use a Medicare Part D prescription plan instead.
People with Medicare that have a yearly income below a certain amount and resources up to a specific might qualify for assistance. The qualifying income and resource amounts may change each year. These income amounts may also be higher if the person provides at least half of the support of family members who are living with them. Those people who qualify may get assitance paying for their medication plan's monthly premium, or for some costs they would normally pay for their drugs. The actual amount of assistance received might depend on the person's income level and their other financial resources. A person should contact a Social Securitly office to find out whether or not they qualify for financial aid.
In order to join a Medicare prescription plan you must have either Medicare Part A or Medicare Part B or both. To be eligible to join a Medicare medical plan that also has drug coverage, you have to have both Medicare Part A and Medicare Part B. You must also reside in the service area of the plan you wish to obtain.
There is a minimum level of benefits that all Medicare prescription drug plans must provide. Past this minimum coverage the plans can offer a variety of combinations of coverage and cost sharing.
You need to join a drug plan when you first become eligible for Medicare, unless you already have prescription that is, on average, at least as good as standard Medicare prescription drug coverage. This minimum coverage level is known as creditable coverage, and if you don't have it you will end up having to pay a penalty if you decide to get a prescription plan at a later time. You will then be required to pay a penalty in addition to your monthly premium for as long as you have a Medicare drug plan. The penalty is calculated using a national average benchmark premium for the current year. The penalty amount would be the number of full months that person was not enrolled in a Medicare prescription plan multiplied by 1% of the current national average benchmark premium. The penalty amount is added to a person's monthly premium.
Different Medicare drug plans vary from one another in which medications are covered and how they are covered. The out-of-pocket costs vary from plan-to-plan, and different plans can also use different pharmacies. Some Medicare prescription drug plans will have a deductible while others will not.
All Medicare Part D drug plans must cover the same categories of medications, but the companies offering the prescription drug plans can choose the medications that are covered in each drug category. This list of covered drugs is often referred to as a drug formulary. Many Medicare prescription plans offer mail order prescriptions. The plans usually have a specific pharmacy they have contracted with to provide mail order drugs.
The amount of money a person may have to spend on medications depends on the particular drugs that person is using. This can lead to a situation where a plan that happens to work well for one person might not work well for a person who happens to be using different drugs. You can also find that the amount of money a person might have to spend can vary depending on the plan they have. Some plans will cover certain medications differently than will other plans. It is possible to find certain medications that are not covered at all by one particular plan but that same prescription is covered by a different plan.
The Medicare Prescription Part D plans categorize drugs into different levels or tiers on their lists of covered medications. The different plans are allowed to divide their prescription medication tiers in different ways. A drug on a higher tier level will tend to be more expensive than a lower tier level drug. Generic medications are likely to be considered tier 1 drugs and will typically cost a policy holder the least amount. Tier 2 drugs will often be referred to as preferred brand-name and will generally cost you more than Tier prescriptions. Tier 3 drugs are usually referred to as non-preferred brand-name prescriptions and the co-payment will tend to be higher than Tier 1 and Tier 2 drugs.
The formulary might not include a medication you use. In most cases, a similar medication that is safe and effective will be available. If a plan removes a medication from drug list; changes a drug on its list to a more expensive tier; or places a prior authorization, step therapy or quantity limit requirement on a drug, the plan will tell you at least 60 days before the change is effective. If your plan makes any of these changes that affect a drug you take, in most cases, the change won't apply to you through the end of the coverage year.
Some drugs might require a person to have to acquire prior authorization from the insurance company before a prescription plan will cover those particular prescriptions. Prior authorization requires that before the plan will pay for a specific medication the prescribing doctor must first demonstrate that there is some sort of medically necessary reason why you must use that particular drug rather than some alternative medication. Step therapy is another form of prior authorization. Step therapy requires that a person first try an alternative drug or possibly multiple alternative drugs before the plan will cover the one in question. Quantity limits are when a drug plan restricts the amount of a particular drug that they cover for a specific period of time. It is possible that your physician may be able to get an amount larger than the quantity limit amount covered if he or she can demonstrate that in a particular case an individual requires an amount larger than that imposed by the quantity limit.
The most difficult and misunderstood part of the Medicare Part D prescription program is the gap in coverage, which is usually referred to as the "donut hole." Most Medicare Part D drug plans have a gap in coverage. The exact dollar amount of where the gap starts and where it ends is likely to change each year. For plans with the coverage gap, you have to begin paying the full cost for your prescriptions once you have used a specific amount of prescriptions during a calendar year. Then when specific amount of money on drugs you reach the end of the coverage gap and have then reached what is sometimes called the catastrophic part of the plan's coverage. Once you have reached this point you will then go back to having a copayment amount for your medications. The copayment in the catastrophic portion of the coverage is usually relatively low. A person may be responsible for a relatively small amount such as 5% of the total cost of the medication. Some drug plans may have coverage through the coverage gap, but this usually result in a higher premium for the plan.