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Health Insurance Basics

Understand Your Medicare Drug Coverage Costs

September 05, 2017

Are you thinking of getting Medicare Part D prescription drug coverage? Because it’s not included in Original Medicare, you may be wondering how to get it — and what it might cost.

What Costs to Expect With Medicare Prescription Drug Coverage

There are two main ways to enhance your health benefits with a Medicare prescription drug plan, which are available from private insurance companies:

  1. Sign up for Original Medicare (Parts A and B) and add a prescription drug plan (PDP), known as  Medicare Part D
  2. Get your Medicare benefits through a Medicare Advantage plan (Part C) that includes Medicare Part D prescription drug benefits, known as an MA-PD

In either case, your Medicare drug costs can include monthly payments, deductibles, and copayments or coinsurance for each prescription. Let’s look at each of these in detail.

How Much Does Medicare Cost With Drug Coverage.

You will have a Medicare premium, or monthly fee, for most Part D plans (PDPs) or Medicare Advantage plans that include prescription drug benefits. The amount is set by the company that provides your plan, so be sure you find out what the monthly payment they charge is before you sign up.

Typically, you’ll receive a bill directly from the private company. Or you can contact them and arrange to have the monthly payment deducted straight from your Social Security check.

What Does Medicare Cost? Most PDPs Have Annual Deductibles.

A Medicare Part D deductible is the amount you must pay out of pocket each year before your drug plan begins to pay its share of your covered drugs. Some drug plans don’t have a deductible, which means you may find their premium is a little higher. A couple more things to note:

  • Limits apply to yearly deductibles. For 2017, the Part D deductible cannot exceed $400.
  • If you qualify for the federal Extra Help program, you may not have to pay the full deductible.
What Are Other Medicare Costs?

After the deductible, if you have one, you will need to pay a portion of the costs for your prescriptions, as either a copayment or coinsurance. A copayment is a set amount, such as $5 for any generic drug. Coinsurance is your percentage of the drug’s costs; for example, your plan might pay 90% of the cost while you pay 10%.

The specific amount you must pay per prescription varies depending upon your plan and:

  • Whether your prescriptions are on your plan’s list of covered medications (also called a formulary).
  • Which “tier” your covered drug is assigned to. Generic drugs typically costing less than brand name and specialty drugs.Enrolling in a Medicare Advantage Plan (Part C), with or without prescription drug coverage.
  • Which pharmacy you use, including whether it offers preferred or standard cost sharing, is out-of-network, or is a mail order service.
  • Whether you qualify for the Extra Help program to pay your Part D costs.
Coverage Gap Costs

Most Medicare prescription drug plans also have something called a coverage gap, which you may have heard called the “donut hole.” It’s an annual limit on benefits that kicks in after you reach a certain amount you and your plan have spent together on covered drugs. Here’s what you should know:

  • You might not enter this gap if your drug costs aren’t high enough.
  • If you do hit the limit ($3,700 in 2017), you might have to pay the whole cost of your medications for the rest of the year, usually at a discounted amount.
  • For 2017, those amounts are 40% of the plan’s cost for covered brand name drugs and 51% of the plan’s cost for covered generic drugs.
  • If your spending reaches the end of the gap ($4,950 out of pocket in 2017), you get what is called “catastrophic coverage,” which begins paying up to 95% of covered drugs again for the rest of the year.
  • Some plans provide extra coverage or cost sharing reductions when you’re in the gap, but may charge a higher premium each month.

Keep in mind, each Part D plan is different and your Medicare drug coverage may change on January 1st of each year. So you may want to compare your plan’s monthly payment, deductible, copayments or coinsurance to other plans on an annual basis.

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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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