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Understanding Medicare drug plans

Knowing that your doctors’ bills and hospital costs are covered by health insurance is comforting, but those enrolling in Medicare must also find the right prescription plan.

A person becomes eligible for Medicare at age 65 unless the person has been receiving disability and social security payments. The initial enrollment period (IEP) is seven months in length. It begins three months before the enrollee's birth month, goes through the month of his 65th birthday, then continues for three months. Enrollment may be completed anytime within that window.

"If you enroll before your birthday month begins, coverage starts on the first day of your birthday month," says Kent Monical, Senior Vice President of Part D and Product Strategy with United Healthcare Medicare and Retirement. "If you enroll during your birthday month or later, coverage starts on the first day of the month following the date you enroll."

If that window is missed, however, the enrollee must wait until the following annual enrollment period to get on the Medicare bandwagon. Open enrollment begins in October each year and lasts into early December. For 2017 coverage, open enrollment is Oct. 15 to Dec. 7, 2016.

Medicare coverage components are labeled Parts A, B, C and D. Part A refers to hospital coverage, Part B pertains to doctor coverage.  These two parts can be referred to as Original (or traditional) Medicare and are managed by the federal government.  Part C is Medicare Advantage, in which a private insurance company becomes involved in covering the costs, and Part D is for prescription drug coverage. Those who have original Medicare must make sure they add Part D coverage to their plan so prescription drugs will be covered.

"Original Medicare (Parts A and B) does not cover most prescription drugs," says Monical. "Part D plan enrollment is optional."

Major Components of Medicare Coverage
Part A Hospital insurance - Covers inpatient hospital, hospice care, skilled nursing facility and some home health care.
Part B Medical insurance - Covers outpatient care, doctor's visits, preventive services and medical supplies.
Part C Medicare Advantage plans - Instead of purchasing Part A and Part B, you can buy a Medicare health plan offered by a private company that will provide you with all of your Part A and B benefits.  Most Medicare Advantage plans offer prescription drug coverage.
Part D Prescription drug  plans - Adds prescription drug coverage to your Original Medicare plan. These plans are offered by insurance companies and private companies approved by Medicare.  

Seek expert advice on Medicare prescription plans

Because Medicare includes so many moving parts and potential pitfalls, it’s a good idea to seek expert advice. Many companies offer independent consulting services to help consumers understand Medicare coverage. Exercise caution if you’re using a broker. Since the broker may benefit financially from your purchase, the person may not always have your best interest in mind.

Each U.S. state also operates a State Health Insurance Program (SHIP), which features a hotline through which Medicare customers, both potential and current, can seek advice. Through phone interviews, counselors will help compare various government-sponsored and private plans at no charge.

Michael Glass, a SHIP representative in Ohio, says it is wise to seek counsel.

"If you are very computer savvy and if you retain information well, you may be able to learn what you need to know online," says Glass. "But I would recommend reaching out to someone because there are things you can miss."

For instance, the premium is not necessarily the bottom line. Glass notes one plan may show a monthly premium of $45 and have excellent drug coverage, while another might have a better-on-the-surface $18 premium, but end up costing the consumer thousands annually in drug costs. It all depends upon the person's individual needs, and a phone counselor can help sort out the particulars.

"We show consumers the top-three recommended programs," Glass says. SHIP representatives can’t advise a consumer to buy a specific plan, but they do provide an individualized breakdown of what each recommended plan will cost.

Monical seconds the notion of consumers taking time to research and examine the details of a plan to see if it fits their needs. Aside from the monthly premium, he recommends consumers should also compare deductibles, copays and coinsurance.

"Make sure the medications you take are included on the formulary, or approved drug list, without a prior authorization or step therapy requirement," advises Monical. You may have to pay out-of-pockets costs if medications are not on the list. If your drugs are not listed but you like the other components of the plan, see if the same drug is offered under a different name.

Monical also recommends checking to see which pharmacies work within your provider's network. "Some plans have preferred pharmacy networks," he says. "By visiting preferred pharmacies, members can typically access drugs at the lowest cost. Other plans may offer a mail-order option, which may reduce copay costs and make it more convenient for beneficiaries to receive their drugs."

Medicare enrollees can visit Medicare.gov to compare plans and review star ratings of different options. Among those options is Medicare Advantage, which is part of the Medicare system that is administered by a private insurance company, and may include drug coverage. Original Medicare pays 80 percent of costs, leaving the enrollee with 20 percent to pay out-of-pocket, says Glass. Gap coverage can help pay those leftover out-of-pocket costs, which can mount quickly when it comes to prescriptions.

Medicare users who are happy with their existing coverage do not need to do anything during subsequent enrollment periods. However, if needs change, it’s wise to examine new options to look for cost savings and more appropriate coverage.

Medicare drug plan costs remain relatively steady

With the annual Medicare changes that were rolled out Oct. 15, 2015, Glass explains, some medicine costs went up and some went down -- depending upon the particular drug.

According to figures from Medicare.gov, in 2016, the average Medicare prescription drug plan will cost $32.50 per month, and the average Medicare Advantage drug plan will cost $32.91 per month.

Prescription drug plan costs vary depending on the following:

  • Drug prescribed
  • Chosen coverage plan
  • Use of in-network pharmacy
  • Use of in-formulary drugs
  • Qualifying for Medicare Part D cost assistance

If you meet certain resource and income limits, you may be eligible for help to pay the costs of a Medicare drug plan. Currently, you may qualify if have an annual income of $17,655 or less and not more than $13,640 in resources. For married couples, those limits are an income of less than $23,895 and resources less than $27,250.

When comparing plans, costs go up proportionally with the number of options offered within the plan. It is important to choose a plan that suits your needs.

Navigating the Medicare coverage gap

Most Medicare drug plans contain a coverage gap that occurs when the drug plan plus the enrollee have reached a provisional limit on covered prescription drugs. For 2016, the limit is $3,310. Once you reach the limit for 2016, you’re responsible for paying 45 percent of the plan's cost for covered brand-name prescription drugs and 58 percent for covered generic prescriptions. The amount that you pay then contributes to getting you out of the gap. The other side of the gap is reached when you have reached $4,850, at which point catastrophic coverage begins and the plan pays 95 percent of drug costs.

Plan ahead for future health

It is wise to purchase a drug plan when you initially sign up for Medicare. If you enroll late for Part D coverage, a penalty will be added to your Part D monthly premium.  If you go without Part D or a creditable prescription drug plan for a period of 63 days or more after your initial enrollment period is over, you can be charged a late fee penalty when you do then add a Medicare drug plan. The penalty will continue for as long as you have a drug plan.

Many new enrollees chose not to include drug coverage because they take few or no medications. However, if a condition develops rapidly outside of the enrollment window, the enrollee could find himself quickly amassing out-of-pocket bills. Industry experts agree it is best to have basic drug coverage at minimum.

More from Kristin Campbell here

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