Medicare Part D – In Detail

Part D Fast Facts

Costs:

  • 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.

 

NO COST, NO OBLIGATION

Answers To Your Medicare Questions



Prescription Drugs Can Be Costly

For those that qualify, there may be programs available to assist with these costs.

Low Income Subsidy (L.I.S.) is a federal subsidy program that provides “Extra Help with Prescription Drug Costs” for Medicare beneficiaries who have limited income and resources.

Some of the features of qualifying for FULL-LIS Benefits include:

  • Can pay for all of part of the Part D Prescription Drug Plan Premium.
  • Can eliminate the annual Part D deductible which is $400 in 2017.
  • Can reduce Prescription coinsurance and copayments to as $3.30 per month supply for Generics, and $8.25 for Name brand drugs.
  • Eliminates the Coverage-Gap which is $4,950 in 2017.
  • Waives any Part D late enrollment penalty (LEP)

LIS= Continuous Election Period (SEP-LIS)

This means you are able, all year long even during the “lock-in” period, to enroll into a new plan for Medicare Advantage– or Prescription Drug Plan.

How To Apply For Low Income Subsidy Extra Help:

  1. Online Application available at: http://www.ssa.gov/prescriptionhelp
    1. Must be present or on the phone with beneficiary- 10-14 Day turn around once submitted online
  2. PDF version of LIS application also available online at http://ssa.gov for you to print and submit.
    1. Must be mailed in for processing
    2. 20-30 Day turn around once mailed to SSA for review