What Medicare Part D Covers - Medicare Consumer - Medicare Consumer

What Medicare Part D Covers

Medicare Part D coverage is for prescription medication. These plans are offered through private insurance companies and not via Medicare itself. Therefore, the benefits that are offered, as well as the premium that is charged, may vary from one Part D plan to another.

Each of the Medicare Part D plans will have its own list of drugs that are covered. This list is called a formulary. Many of the prescription drug plans will place their covered medications into different “tiers” on their formularies – and in turn, the drugs that are in each of these tiers will have a different cost.

For example, a medication that is listed in a lower tier will typically cost less than one that is listed in a higher tier. However, there may be certain cases in which your prescriber thinks that you need one particular drug that is listed in a higher tier rather than another one that is listed on a lower tier in which you may be able to get an exception for a lower co-payment amount.

In addition to prescription medications, there are other types of drugs that Medicare Part D may cover. For example, except for vaccines that are covered under Medicare Part B, Medicare drug plans are required to cover all commercially available vaccines, such as the shingles vaccine, when it is medically necessary in order to prevent illness.

Also, in most instances, the prescription medications that are received in a hospital outpatient setting, such as an emergency department or during observation services, are not covered by Medicare Part B. (These are sometimes referred to as “self-administered drugs). Therefore, Medicare Part D may cover these medications under certain circumstances. In this case, you may need to initially pay out-of-pocket, and then submit a claim to your Medicare Part D plan for reimbursement.


The Cost of Medicare Part D

The costs that are related to Medicare Part D will vary, based upon a number of factors. These will include the medications that the enrollee requires, whether or not the medications are listed in the plan’s formulary, and / or whether the participant uses a pharmacy that is listed in his or her Part D plan’s network.

In addition, the enrollee may also be required to pay an annual deductible as a part of their Medicare Part D coverage. The deductible may be required to be paid before any of the benefits will be paid out from the plan. Although the actual amount of the deductible may vary, it is not allowed to exceed $320 (in 2015).


How To Obtain Medicare Part D Coverage

There are two ways that you can obtain Medicare Part D coverage. One way is to purchase a stand-alone Part D plan that adds prescription drug coverage to your Medicare Part A and Part B (Original Medicare) coverage. Alternatively, you can join a Medicare Part C plan – also known as Medicare Advantage – that may already provide prescription drug coverage within the overall plan.

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