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What are the Medicare Part D benefits?
Medicare Part D helps to cover the costs of your prescription drugs. Medicare-approved private insurance companies offer prescription drug plans, also called PDPs. If you have Medicare Part A or Medicare Part B, you are eligible for Medicare prescription drug coverage. You can enroll in any of the Part D plans that serve the area where you live. Our easy-to-use Part D Comparison Tool can help you compare and choose a plan.
The Annual Election Period (or Open Enrollment Period) for Part D plans is from October 15 to December 7. During this time period, anyone with Medicare can enroll in a plan or change from one plan to another. (You can enroll anytime if you qualify for Extra Help with your prescription drug costs.) You may also be able to join, switch, or drop Medicare drug plans at other times, such as when you move from a plan's service area, or if you live in a nursing home or other assisted care institution. In these cases, you will need to join or switch as soon as possible.
What should I consider when choosing a plan?
- Costs - The Medicare Plan Comparison Tool helps you compare costs such as premiums, co-payment/co-insurance and deductible expenses. We can also help you compare annual costs, based on the drugs you take.
- Doctors/Providers - If you are part of a Medicare Advantage Plan like an HMO or PPO, and get your Part D coverage as part of this plan, you need to make sure that you're able to visit the providers you want. If the provider you prefer is out of network or referrals are needed, you will need to check if there will be any additional costs if you continue to see them.
- Travel - Are my drugs covered if I travel (or live part-time) in another state? If you are part of a Medicare Advantage Plan, and get your Part D coverage as part of this plan, you should make sure that your plan provides coverage in that state.
What are my Part D coverage costs?
- Premium - You pay a monthly premium for Part D, which varies from plan to plan and state to state. The average monthly Part D premium in 2013 is around $30.
- Deductible - The standard Part D deductible is $325 in 2013. (The deductible will go down to $310 in 2014.) However, your actual deductible will depend on your plan. Many plans have a deductible, and you usually pay all of your drug costs up to that amount. Some plans do not have a deductible (called $0 deductible plans), but these plans typically have higher premiums or higher copayment/coinsurance amounts.
- Initial Coverage Stage - Once you reach the deductible amount, you pay a copayment or coinsurance in the Initial Coverage Stage until your total drug costs (what you pay, plus what your plan pays) reach $2,970 ($2,830 in 2014). Once this limit is reached, you will enter the Coverage Gap or Doughnut Hole.
- Coverage Gap Stage - The Coverage Gap begins once you reach the Initial Coverage Limit and ends when you spend a total of $4,750 out of pocket ($4,550 in 2014). If you reach the gap in 2013, you will get a 52.5 percent discount on covered brand-name prescription drugs and a 21 percent discount on covered generic drugs. (In 2014, you'll get a 52.5 percent discount on brands and a 28 percent discount on generics.) There will be additional discounts in the Coverage Gap each year through 2020, when you will have full coverage in the gap.
- Catastrophic Coverage Stage - Once you have reached the out-of-pocket limit in the Coverage Gap, you qualify for catastrophic coverage. You will pay no more than 5 percent of your drug costs for the remainder of the year in this stage. Only a small percentage of beneficiaries reach the Catastrophic Coverage stage.
Does Medicare provide extra help for my Part D costs?
Yes, if you are in a Medicare Part D plan and qualify for assistance, you can get Extra Help from Medicare to pay your monthly premiums, yearly deductibles, and prescription copayments. The amount of help you receive will depend on your income and resources.
You automatically qualify for Extra Help if you have any one of the following:
- You have complete Medicaid coverage.
- You get assistance from a state Medicaid program for paying Part B premiums as part of a Medicare Savings Program.
- You get Supplemental Security Income (SSI) benefits.
Even if you don't automatically qualify for Extra Help, you may still apply, as long as you have a Medicare prescription drug plan. If you think you may qualify for Extra Help, you can call Social Security at 1-800-772-1213, visit the Social Security website (www.socialsecurity.gov), or apply at your State Medical Assistance (Medicaid) office
What drugs are not covered?
There are certain drugs or categories of drugs that the Medicare program does not cover. These are called excluded drugs. Some plans may include these drugs as an added benefit.
The Centers for Medicare & Medicaid Services (CMS) does not require these categories of drugs to be covered:
- Weight loss or weight gain
- Fertility
- Cosmetic (e.g., hair growth)
- Cough and cold
- Nonprescription drugs
- Smoking Cessation (prescription smoking cessation drugs are covered)
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Currently, barbiturates (seizure drugs) and benzodiazepines (anxiety drugs) are also excluded from the Medicare program. However, as of January 1, 2013, Part D plan must cover barbiturates "when used to treat epilepsy, cancer, or a chronic mental health disorder" as well as benzodiazepines.
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