Applying for a Medicare prescription drug plan can be a daunting task. Yet, with accurate guidance, you can easily apply for the plan that best suits your needs.
These plans are available to those enrolled in Original Medicare or as an added benefit for Medicare Advantage beneficiaries. Part D plans, as they are called, vary in terms of coverage, cost, and other essential features.
In 2023, The Centers for Medicare & Medicaid Services (CMS) updated Medicare to provide more comprehensive coverage for prescription drugs. The new coverage includes more generic and brand-name drugs and preventive care services such as vaccinations and screenings.
This article will explain how to apply for a plan, what types of plans are available, and how to ensure you get the best plan for your needs. We will also discuss common issues when applying for a plan and provide tips on ensuring you get the best coverage possible.
What Is Medicare Prescription Drug Coverage?
Medicare Prescription Drug Plans (PDPs) help cover the cost of prescriptions. These plans are available to those enrolled in Medicare Part A and/or Part B or as stand-alone coverage. The plans vary in coverage, cost, and other features. The 2022 Inflation Reduction Act made it easier for seniors to access the medications they need by making them more affordable. It also added these changes to Medicare Part D plans, including:
- Expanded coverage for generic drugs
- Provided more discounts on brand-name medications
- Capped the most monthly sharing costs for insulin at $35
- Eliminated the costs of certain vaccines altogether.
These benefits will help reduce out-of-pocket costs and make accessing medications more accessible.
Who Is Eligible for a Medicare Prescription Drug Plan?
In 2023, the eligibility requirements for Medicare prescription drug plans expanded to include individuals under the age of 65 who have specific disabilities or chronic conditions. Medicare prescription drug plans are now available to:
- People 65 years of age or older
- People with specific disabilities
- People with end-stage renal disease are also eligible
To be eligible for a plan, you must also have a valid Social Security number and be enrolled in Medicare Part A and/or Part B. Additionally, living in the plan’s service area would be best.
How To Apply and Get Prescription Coverage
Applying for Medicare Prescription Drug Plan (PDP) can seem daunting. Still, the process is relatively straightforward if you follow these steps.
Decide Which Plan Best Meets Your Needs and Budget.
Complete an Application To Enroll.
You can accomplish this in a couple of different ways. You can enroll through the Medicare Plan Finder website or visit your new plan to sign up. If those aren’t viable options, you can enroll with paper forms and mail them in. You can also call your chosen plan or speak with Medicare over the phone to apply.
Submit Any Additional Documentation Required by Your Chosen Plan.
Once you’ve submitted the required information, wait to be approved! To learn more and get started, visit the Medicare website for more information.
Which Plans Provide This Kind of Coverage?
There are a couple of different ways to apply for prescription drug coverage.
- Stand-alone (part D) Medicare drug plans
- Medicare Advantage Plans (Part C)
- Other Medicare Health Plans with drug coverage
Medicare drug plans come in different forms, such as stand-alone prescription drug plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs). Each plan has its own set of rules and regulations, so it is crucial to understand what each plan covers before enrolling. Some plans may offer additional benefits such as vision or dental coverage. Understanding the different plans available can help you decide which is right for you.
Medicare Prescription Drug Plans (PDPs) Part D
Part D PDPs are an add-on or extra health insurance plan that helps cover the cost of prescription drugs. These plans are approved by Medicare and offered by private insurance companies. They provide coverage for both generic and brand-name drugs, as well as some preventive services. PDPs Part D also offers additional benefits such as coverage for certain medical supplies, home health care, and mental health services. With a PDP Part D plan, you can save money on your prescription drug costs while still getting the medications you need to stay healthy.
Medicare Advantage Plan (Part C)
A Medicare Advantage Prescription Drug Plan (MA-PD ) is a health insurance plan that covers hospital and medical services and prescription drug coverage. It is an alternative to Original Medicare (Part A and B). With an MA-PD plan, you can get the same benefits as Original Medicare, plus additional benefits such as vision care, hearing aids, dental care, and more. Additionally, many plans offer prescription drug coverage to get your medications at a lower cost.
Other Medicare Health Plans With Drug Coverage
Other health plans available to those who qualify include TRICARE, VA Benefits, and FEHB, three of the most popular options offering drug coverage. These three plans service active-duty military personnel, veterans, federal employees, or their families. If one of these plans includes drug coverage for the medications you need, you may not need to enroll in Part D.
What To Consider When Making Your Choice
Formularies and Tiers
A formulary is a list of prescriptions that you can use to help you determine which Medicare plan is right for you. CMS requires that all Medicare plans offer six protected categories of essential drugs. Coverage for everything else can vary by your plan’s formulary. Check if your prescription is covered before applying for a PDP. Medicare Part D plans are divided into three tiers:
- Tier 1 – Generics
- Tier 2 – Generics plus common drugs
- Tier 3 – Brand name and preferred drugs
Each tier contains different copayment or coinsurance amounts for medications, medications with different levels of coverage, and cost-sharing requirements.
Fees and Surcharges
When choosing the best Part D and Medicare Advantage plans, one of the most important considerations is your MAGI or modified adjusted gross income, which will determine the available plans. Additionally, higher-income people may be subject to income-related monthly adjustment amount (IRMAA) surcharges, which can significantly increase their premiums. Knowing these details can help you make a more informed decision that best meets your needs.
Preferred Pharmacy Networks
Preferred pharmacies offer services in-network, meaning they accept your prescription drug plan and also can provide discounts on medications. Knowing which pharmacies are in-network for your plan will help you save money on medications and ensure that you have access to the drugs you need.
Star Ratings by Medicare
Medicare Advantage and Part D prescription drug plans have a Star Ratings system. The ratings are based on the quality of health and services provided to members, with two to five stars and 5 being the highest. To learn more, read the CMS 2023 Star Ratings Fact sheet.
Are There Any Drawbacks to Getting This Kind of Plan?
PDPs are a great way to access prescriptions at an affordable cost, but there are some drawbacks to be aware of before signing up. These include higher premiums, limited coverage, the possibility of having to pay out-of-pocket costs for certain medications, and potential gaps in coverage due to enrollment periods. Additionally, PDPs may not cover all your medications or require you to switch to generic versions of your drugs to save money. Be sure you understand these downsides to determine whether or not this type of plan is right for you.
Medicare Advantage Plan Issues
Joining a Medicare Advantage Plan will usually provide coverage for prescription drugs. Suppose specific Medicare plans don’t provide or decide not to supply drug coverage. In that case, you can join a different plan. However, remember that if you’re enrolled in an HMO or a PPO and join a stand-alone drug plan, you’ll be removed from your Medicare Plan and re-enrolled in the Original Medicare. You may join an individual Medicare Part D drug plan without having to forfeit your existing healthcare coverage if you fall under any of the following categories:
- Private Fee-for-Service Plan
- Medical Savings Account Plan
- Cost Plan
- Certain employer-sponsored Medicare health plans
If you have queries about how your current health insurance will be affected, contact your plan provider for clarification. Make sure you understand how the coverage you want works with the prescription coverage you already have.
Late Enrollment Penalty
If you enroll in Medicare during one of these three enrollment periods
- The seven-month enrollment period around your 65th birthday
- The open enrollment from October 15th to December 7th
- Special enrollment periods
Then you may have a late enrollment penalty applied to your plan once you sign up. Medicare will charge 1 percent of the “national base beneficiary premium” (roughly $32.74 in 2023) times the number of whole months you’ve been uncovered by a plan. This premium will be rounded to the nearest 10 cents and added to your monthly premium.
How To Get More Information About These Plans
Need more help understanding your prescription benefit options? You can speak with a private insurance company representative to learn more about your Prescription Drug Plan options. Blue Cross and Blue Shield of Kansas Medicare representatives are available to help guide you through signing up for a Medicare drug plan. These fellow Kansas will be able to provide you with detailed information on what is covered and how much it will cost. To learn more, call 800-520-3137 or visit https://www.bcbsks.com/prescription-drugs.