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Learn the Basics About Medicare Part D Drug Coverage

August 30, 2017

Did you know Original Medicare does not cover most prescription drugs you buy at a pharmacy? That’s why it’s important to get benefits from a private insurer through a stand-alone  Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug benefits.

Prescription Drugs and Medicare Part D Coverage

All Part D drug plans must give at least a standard level of Medicare benefits to make sure plan members can get medically necessary drugs to treat their conditions. And every Medicare prescription drug plan has its own specific list of medications that are covered, which is known as a formulary. While each drug list is unique, they all have some things in common:

  • Plans cover both generic and brand-name prescription drugs.
  • The drug list must include a range of drugs in the most commonly prescribed categories and classes.
  • Although one of your specific medications might not be included, a similar drug should be available.

It’s possible your plan might make some changes to its drug list during the year because drug therapies change, new medications are released, and new medical information becomes available. If the change involves a drug you’re currently taking, your plan is required to give you written notice at least 60 days before the date the change becomes effective. Or when you request a refill, they can give you written notice and a 60-day supply of the drug under the same plan rules that applied before the change.

Medicare Part D Drug Coverage Organizes Drugs by Tiers

To help keep your costs down, most prescription drug plans have different “tiers” or levels of cost. Most tiers are arranged so that a drug in a lower tier costs less than a drug in a higher tier.

Typically, there are three to six tiers. Here’s an example of four-tier Medicare drug benefits:

  • Tier 1: Most generic prescription drugs, with the lowest copay level.
  • Tier 2: Preferred, brand-name prescription drugs, with copays in the midrange.
  • Tier 3: Non-preferred, brand-name prescription drugs that have a higher copay.
  • Tier 4 or Specialty Tier: Unique, very high-cost medications, with the highest. copays or coinsurance that requires you to pay a percentage of the cost.
More Things to Keep in Mind About Medicare Part D Coverage

In addition to drug lists and tiers, there are some rules that plans use to make sure certain drugs are used correctly and only when medically necessary. These help keep costs down and ensure your safety:

  • Preapproval - Your doctor may need to contact your plan before writing a prescription to confirm that the drug is medically necessary and appropriate for your condition.
  • Step therapy - If more than one medication can do the same thing for your condition but at different costs, your doctor will prescribe a less expensive drug first. Then you can “step up” to more a more expensive drug if that one isn’t working.
  • Quantity limits - Your plan may limit the amount of some drugs you can get at one time. If you refill a prescription too soon, or if you’re prescribed an amount above safety standards, your doctor may need to contact the plan before you can refill your prescription.

If your plan doesn’t cover a prescription your doctor says you need, you do have the right to ask for an exception. Usually your doctor will need to submit a written statement that explains the medical reason for the request, such as why similar drugs covered by your plan won’t work for you or why a coverage rule, like step therapy, should be waived.

Remember, Original Medicare benefits do not include all the prescription drug coverage you probably need. Now that you know how Medicare Part D drug coverage works, you can compare plans and choose one that best covers your current medications and helps protect your health.

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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

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