Part D Fast Facts
- Prescription drug coverage premiums vary from plan to plan
- In Colorado, the approximate range in 2017 is from around $17 to $130+ per month varying greatly by insurance company and plan.
- The Catastrophic Coverage phase protects you from extremely high drug costs
- Premiums can/do change from year to year
What is A Formulary: Drug List?
Formulary: List of drugs that an insurance plan covers
Drug plans have a tiered formulary. This means the plan divides drugs into groups called “tiers”.
Generally, the lower the tier, the lower the copay and vice versa.
Understanding Part D Payment Stages:
If your plan has a drug deductible, you will pay the total network cost of the drug until the deductible has been satisfied. Then you will move into the initial coverage stage.
The 2017 CMS Standard Benefit Design deductible is $400
Note: On January 1st of each year, the coverage cycle starts over and the dollar limits can/will change. Amounts listed reflect 2017 numbers.
Important Coverage Details:
Plans may have the following coverage rules:
- Prior authorization
- You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
- Quantity limits
- Limits on how much medication you can get paid for by insurance at a time.
- Step therapy
- You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.
If you or your prescriber believe that one of these coverage rules should be waived, you can ask for an exception.
Part D High Income: IRMAA Penalty
Part D Late Enrollment Penalty
Note: If you get Low Income Subsidy, you don’t pay a late enrollment penalty.
Penalty is 1% of the national average premium for every month you go without credible drug coverage with a gap of more than 63 days since last credible coverage was in-force.
Here are a few ways to avoid paying a penalty:
- Join a Medicare drug plan when you’re first eligible.
- Don’t go 63 days or more in a row without a Medicare drug plan or other creditable coverage.
- Tell your plan about any drug coverage you had if they ask about it.