Choosing between eating or buying needed medication. It’s a story that’s told all too often, especially among the elderly. In some cases, it’s pay the electric bill or take their medication, so they turn the heat down and put an extra blanket over their legs. They cut their pills in halves or thirds. And they hope it will get them through. For people with little money and no prescription drug coverage, this is an all-too-common reality.
With Medicare Part D (Prescription Drug Coverage), it’s possible to have proper coverage for needed medications so they cost much less on an out-of-pocket basis. If you need medications when you’re younger, and see that you’ll need them as you age, this can be a good choice for you. Even if you’re not currently taking any medication, though, the odds of needing a medication will increase as you age. Getting Medicare Part D can help protect you.
Why Isn’t This Coverage Automatic?
When people qualify for Medicare, they only get the standard part that covers doctors and hospitals. There are other options for further levels of coverage, including Part D, but these other coverage options have to be paid for. If you take medications this coverage can be quite valuable, and for people who may need medications in the future, it can be an investment toward protecting both their health and their finances. While many medications are affordable, some are still extremely expensive.
Part of the reason that Part D is not automatically included is due to the already high cost of health care. Additionally, the price of some medications, especially those for serious and chronic conditions, can be excessive. If all of this was paid for without any help from the people who need the medications, it could become a problem for an already burdened health care system. With that being the case, requiring payment for Medicare supplements like Part D helps the Medicare system continue.
What Does Medicare Part D Cover?
Medicare Part D is the prescription drug coverage supplement to the Medicare program. It covers needed medications for people who are on Medicare and who choose to pay for the additional coverage. Both traditional Medicare and Medicare Advantage (Part C) have options for you to also enroll in Part D. Some medications are covered without the need for Part D, but these are generally medications you’re given while in the hospital or as part of your discharge from a medical facility.
Additionally, some drugs that require a doctor to administer them, such as infusion drugs, may be covered without the need for Part D. For most other types of medications, Part D is required and will cover at least a percentage of the cost of your medications. Generally, Part D will cover all types of prescription medications. There may be some exceptions, so it’s very important to work with your doctor to ensure your medications are covered. You may need to switch medications in some cases.
How Much Does This Coverage Cost?
The cost of Medicare Part D will depend on several factors, including the cost of your prescriptions. Whether you get low-income help, if your medications are on the list of covered drugs, and whether you use an in-network pharmacy will also affect how much you will need to pay in order to have Medicare Part D. If you feel your costs are too high there are options you can consider, so you can try to lower the amount you’re paying for the coverage and the medications you need.
Especially if you have a very low income, there is help available. One of the things you may be able to do is get part of your Part D costs paid. You may also qualify for help with the actual price of the medications you take, or your copay. Not everyone who has Medicare and Part D coverage realizes this help is available, so it’s very important that you explore all your options and consider those choices carefully. Saving money and keeping good coverage should be the ultimate goal.
Avoiding the “Donut Hole”
The donut hole or coverage gap is a serious concern for people who have Part D coverage through Medicare. This gap comes about when you’ve paid in a certain amount for your medications and have reached an initial coverage limit. At that point the Part D plan has paid as much as they have agreed to cover for your medications during a one-year time frame. Of course, you still need your medications, regardless of how much they actually cost.
Once you reach your initial coverage limit, you’ll be asked to pay a bit more for your medications going forward. Fortunately, paying more means you’ll reach the catastrophic coverage phase faster. Once you reach that phase, you’ll have a small copayment for the rest of the year, and won’t have to pay nearly as much for your medications. Depending on the cost of your needed prescriptions, you may reach the donut hole and the catastrophic coverage limit very quickly,, or not at all.
Reducing the Donut Hole Costs
There are also some other things you can do to try to avoid the donut hole, so you don’t suddenly have to pay more for your medications. One of the ways to avoid this problem is to ask your doctor for generic or less expensive medications options. It’s not a good idea to switch in some cases, but many people do have the option to take generics or take medications that are similar but a little different from what they currently have. That can help them reduce their costs.
Another way to pay less and avoid the donut hole is to be sure you’re using your Medicare Part D plan card every time you get your medications, and always get them through an in-network pharmacy. That helps you pay less for your prescriptions every time you get them, which keeps your costs down and further away from adding up to where you might fall into the coverage gap. Not everyone can avoid it, but if you can avoid the gap it’s financially easier to do that.
Also apply for the Extra Help subsidy if your income is low. That will protect you from the donut hole more easily, and can prevent you from needing to do without your medications because the price of them suddenly increased. Even if you’re not sure if you qualify, there’s no harm in applying. You want to get all the help you can with your medical bills, and that includes how much you might have to pay for prescriptions throughout the year.
How Do You Get Medicare Part D?
You get Medicare Part D through signing up specifically for that program. Once you have Medicare or Medicare Advantage, or you’ve been notified that you are about to become eligible for Medicare for the first time, you can enroll in any supplemental programs that go with the standard Medicare benefits. There are specific enrollment periods you must follow, though, or you may find that you have to pay a penalty or wait longer for your coverage to begin.
Instead of taking the risk of paying too much or being without coverage, be proactive in asking about when you need to sign up for everything. Medicare has agents who can help you navigate everything, so you don’t miss out on the coverage you really need and want. When you sign up for Medicare initially, you can also sign up for Part D. if you choose not to, you’ll be able to sign up at a later time but it won’t be as easy. Be sure to ask plenty of questions, so you know how the signup process will work at a later date.
Is This Permanent Coverage?
As long as you keep paying your premiums for Part D, your coverage will remain in place. If you stop paying premiums, or if you disenroll, you’ll no longer have Part D coverage and your medications won’t be paid for any longer. However, you have to actively make a change for your coverage to go away. It’s not something that will be canceled without your knowledge unless there are serious and significant changes to the Medicare program overall. There are no current plans for any of these changes.
Once you’ve enrolled in Medicare Part D and have started paying your premiums, you’ll have coverage that you don’t need to worry about. The medications you currently take, along with the ones you may need to take in the future, will be covered under your plan. It’s important that you find an in-network pharmacy close to you to get the biggest benefit from your Part D coverage. You may need to switch pharmacies in order to be in-network, but the savings is generally well worth making the change.
Can You Cancel Medicare Part D Coverage?
If you signed up by mistake or you aren’t using Part D coverage, you can disenroll from it. You may need to wait until an open enrollment period where you can make changes. During that time, you should carefully evaluate any Medicare supplement programs you have purchased, so you can decide if you want to keep them or not. If your situation changes in the future you’ll be able to re-enroll. But keep in mind you may have to wait for an open enrollment period again.
What If You Have Other Insurance?
If you have other insurance that offers prescription drug benefits, keeping that insurance is generally a good idea. That’s especially true if the other insurance comes from the military, veteran’s benefits, or the federal government. There are many other types of insurance, as well, such as employer-sponsored plans, Medicaid, food stamps, long-term care, and more. Medicare Part D can affect and be affected by these insurance and benefit options.
It’s best to ask about how you’ll be affected before you enroll in Part D, just to make sure it won’t affect any of the other needed benefits you’re getting. That way you reduce your risk of losing out on something you really need, and increase your chances of getting the maximum level of benefits you’re eligible for. When it comes to people on very fixed income, those with disabilities, and the elderly, that benefit level can be extremely important and should be carefully considered.
What’s the Bottom Line With Part D Coverage?
The bottom line is that Medicare Part D coverage can be extremely helpful for people who need help to pay for expensive medications. Even with the “donut hole” gap in coverage, people can benefit from having protection from the high costs of some medications. With that in mind, though, Part D may not be for everyone. Someone who is not taking any medications at the time of Medicare enrollment may choose not to get Part D because it isn’t needed.
Knowing they can enroll later if they need to is generally enough for them to feel secure in avoiding the coverage if they aren’t currently in need of it. If you choose that option, just make sure you understand how and when you can enroll at a later date. That can help you avoid ending up without any coverage for a long period of time if you suddenly have to start taking medication. Many medications have a generic option that’s affordable, but that’s not true of every medication.
If you’re not sure about Part D coverage, ask questions. The time to decide on whether you want the coverage isn’t when you’re stressed out and overwhelmed by the cost of medications you now have to take. It’s better to make a more relaxed and informed decision whenever possible. so consider that carefully and know your options for Part D even if you don’t choose to enroll right now. That way you’ll know what steps to take later if you decide that you need the Part D coverage and want to add it to the Medicare coverage you already have.