Why we needed a Part D benefit?

Before Medicare included an optional prescription drug benefit, many members had to choose what they should do first, either to pay their electric bills and buy their groceries or getting first their prescriptions filled. However today, it has improved especially for seniors who take the time to carefully choose a Part D plan that covers their medications with potential savings each year. 

Here are the seven rules of the road when choosing Part D Prescription Coverage:

1.     Know your shopping window.

You have from October 15 to December 7 to shop around for a new Part D plan or change your Medicare Advantage coverage for the following year. It’s important to keep in mind that changes will take effect starting in January, leaving you the option to change your mind more than once during the fall open enrollment window. And if you’re enrolled in a Medicare Advantage plan, you get another opportunity to change your mind during the Medicare Advantage open enrollment period that runs from January 1 to March 31, although only one plan change is allowed during that January-March window.

It pays to be prepared because most people can’t change plans outside of this shopping window. Some Medicare members can safely remain in their current plan without increased costs from one year to the next. In fact, some need to remain for other reasons such as having their best option for Medicare health plan benefits and doctors tied to their Part D coverage.

But for many Medicare beneficiaries and their caregivers, shopping around for new and better options will help them save money and ensure they can continue benefitting from the Medicare program’s promise of affordable and accessible health coverage for Americans who need it most.

2. Check your Medicare Advantage plan.

If you have a Medicare Advantage plan, you automatically will have your drug benefits through that plan rather than a separate Part D insurance. If you receive your hospital and physicians benefits through a private Medicare Advantage plan, that same insurer probably provides your Part D coverage as well. This means that when you change your Part D plan, your health and hospital benefits change too.

You should consider switching Medicare Advantage plans if your plan’s Part D formulary for the coming year would limit your ability to continue taking your current prescriptions. Just be sure to choose a replacement Medicare plan that will also cover your current health care providers in addition to covering your medications

3. Check your formularies and drug costs.

Plans change their lists of covered drugs or formularies and their costs each year. Because prescription drugs are expensive, plans need to change their benefits and can require you to pay more (or less) for the same medication from one year to the next.

Another thing is that Part D plans usually add requirements and it is known as prior-authorization or pre-certification, which means that you receive the plan’s approval before covering your current medications next January. 

If you can’t find a plan that covers all your medications, you may be able to work with your doctor to get your existing plan to cover the drug anyway.  What you need to do is you should keep any letters from your Part D insurer if it has approved coverage for one of your medications this year as evidence to support your case.

If you take multiple medications, not all medications are covered by the plan. Thus, you need to pay attention to how much each of your drugs would cost, and consider enrolling in the plan that best covers the most expensive drugs you take.  In addition, your Medicare prescription drug insurer must generally offer enrollees a 90-day filling of their current medications when the plan benefits change from one year to the next under certain circumstances. There are conditions attached to this policy, known as a “transition fill,” so be sure to know your insurer’s rules – while ensuring the plan follows through on its obligations to support you as Medicare beneficiary.

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If your prescription medication is excluded by your Part D plan, a prescription discount card may lower the price of your medication.

4. It pays to shop around.

Even without major coverage changes, new and different offerings can come to your area, so it still pays to shop around for new plans. 

To make Part D coverage palatable to budget, the law created a “donut hole” (also known as the coverage gap), with this, you have to pay your drug costs yourself while you were in the donut hole.

The Affordable Care Act has closed the Part D donut hole as of 2020. But the donut hole is still relevant in terms of how your drug costs are tallied up to determine whether you reach the catastrophic coverage limit for the year. And although there’s no longer a donut hole in terms of the amount that beneficiaries with standard plans pay for their drugs after reaching the initial coverage limit, the out-of-pocket costs for your medications will vary from one Part D plan to another, depending on the plan design. 

Shopping around each year is the best way to ensure that you’re getting the coverage the best fits your needs.

5. Part D premiums aren’t everything.

Part D premiums aren’t the whole story because benefits under Part D change from year to year, so it pays to closely examine your costs under each plan available. Some plans offer generic drugs without copays; if those offerings apply to your medications, you could save a lot of money throughout the course of the year.

In addition, some Part D plans offer enhanced coverage beyond a minimum level of prescription drug benefits required of insurers by the federal government. In 2020, the minimum coverage levels include a deductible of no more than $435, and then out-of-pocket costs that don’t exceed 25 percent of the cost of brand-name and generic drugs. But some Part D plans have lower deductibles or no deductibles at all, and some plans offer lower out-of-pocket costs after the enrollee meet the deductible.

As good as it sounds, enhanced Part D plans may not end up being the best choice because higher premiums might more than negate the savings offered by the lower co-pays and deductibles than the enhanced plans advertise. This is why it is so important to consider your costs across the entire year, including premiums, co-pays, and co-insurance, before making a decision on next year’s Part D plan.

6. Better benefits for lower incomes.

Low-income members, including those who have both Medicare and Medicaid, can wind up with different benefits. You probably know if you have Extra Help (Low-Income Subsidy or “LIS”) with your Part D coverage if your copays in 2020 are no more than $3.60 for generics and $8.95 for brand-names. Cost-sharing for a small segment of enrollees, between 135 and 150 percent of the poverty level, is a fixed percentage rather than a copay but is still reduced compared to those who don’t receive a Part D subsidy.

Also, it is important to note that, in addition to having better coverage with lower copays, Part D members with Extra Help also have the ability to change plans up to once per month – even outside of open enrollment. But this doesn’t mean you shouldn’t be proactive about choosing a plan that covers your medications during the regular enrollment window for Medicare each fall, but,  it means you have some flexibility if something does come up mid-year and you need to change plans again.

7. Part D plan Star Ratings

Pay attention to Star Ratings when selecting your plan. Although your primary focus should be on whether your medications will be covered, the federal government’s Star Ratings program shows how well a Medicare Advantage or Part D plan is doing in a number of ways that impact you. 

Good star ratings – especially ratings of four stars and above – can mean a plan has demonstrated quality customer service and has a track record of paying attention to your many health care needs (such as periodic screenings or health assessments). By that same token, you should be wary of plans with fewer than four stars. Those plans often have a track record of mistreating their members, providing subpar customer service, and being slow to process member claims and appeals – delaying or even preventing access to needed health care.

In other words, just be savvy.

The best way to select a Part D plan is to pay attention and be a savvy shopper. You can ask for help either from a friend, neighbor, family member, or an advocate you can access through your senior center or Social Services office.

By taking advantage of resources available to you free of cost, you can be confident you’ll have access to your medications and health care providers, while knowing you selected a plan for next year that is more likely to take care of your needs. Seniors and people with disabilities deserve no less.