Medicare Part D – Your Drug Plan

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Deena Flinchum

In the decade that the Medicare Part D drug plan has been in existence, it has become a major factor in Medicare beneficiaries’ being able to afford their drugs.


Unfortunately, it is a system that can be extremely complicated and difficult to understand if you are not used to working with it. If you are planning to do your own enrollment for a drug plan, you really need to know how to use programs and systems on the Internet, in particular Medicare.gov.

There are three things that determine what drug plan is best for you: what drugs you take, what pharmacy you use and whether or not you qualify for a low-income subsidy from the federal government to help pay for your drugs.

It is important to be accurate in recording your drugs. You should pay particular attention to the name of each drug and list it in the correct form – generic or brand. Generics are much less expensive, and often Part D insurance companies will cease to cover brand name drugs that are offered as generics.

Part D plans must cover a wide range of drugs in all major categories but do not have to cover all drugs. Your choice of plan usually should cover all of your drugs; however, it is sometimes better to select one that doesn’t cover an inexpensive drug if it covers the more costly drugs better.

Part D drug plans form business relationships with pharmacies so that the price you pay for your drugs may vary depending upon which pharmacy you buy them from. Some plans may exclude certain pharmacies from their networks altogether.

If a pharmacy is in a plan’s network, it can be either standard, noting a regular discount, or preferred, noting that it offers the best prices. It is important to recognize that many smaller pharmacies that are not part of the large chains often provide more personalized service, which can be an important factor in safety and convenience, even if they are slightly more expensive.

Qualifying for a low-income subsidy for your drugs can be helpful in three ways. First, if you fully qualify, you may pay a small premium and no more than $3.30 per month for generic drugs and $8.25 for brand names – a huge savings when you consider that some brand name drugs may cost hundreds of dollars.

You can qualify for this subsidy by applying to the Social Security Administration if your income is no more than $1,508 per month if single and $2,030 if married.

Second, with this subsidy, you can change Part D drug plans all year long instead of just during Open Enrollment (Oct. 15-Dec. 7).

Those without the low-income subsidy can only change plans during Open Enrollment. Finally, obtaining this subsidy can eliminate penalties for failing to sign up for your drug plan at the proper time, as well as eliminating the infamous doughnut-hole, where your drugs can be most expensive.

There can be restrictions on obtaining your drugs even if they are covered by a plan. A drug plan can restrict the number of pills that they will cover in a 30-day period or impose step therapy, whereby it will cover your prescribed drug only if you try a lower priced one first and it proves ineffective. Prior authorization, a restriction becoming more common, can usually only be overcome by your doctor’s justifying to the plan that your particular drug is medically necessary.

Most drugs have no restrictions other than quantity limits, and those limits fall well within common prescription requirements. Step therapy and prior authorization are usually reserved for higher priced drugs that deal with less common conditions.

In my opinion, the drug plans are one of the most complex of the Medicare components to understand and to maneuver on your own. Even if you feel comfortable signing up for Medicare Parts A and B and securing a Medicare Supplement, you may want to consult with a Virginia Insurance Counseling and Assistance Program (VICAP) counselor about your Part D drug plan, especially if you are new to Medicare. VICAP counselors have to pass annual certification tests in order to be allowed to counsel Medicare beneficiaries.

Anyone needing help in signing up for Medicare or having questions regarding any aspect of Medicare can receive personalized assistance from the New River Valley Agency on Aging at 980-7720. The Virginia Insurance Counseling and Assistance Program (VICAP) at the Agency can help you find answers to specific Medicare questions.