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Medicare Part D (Prescription Drug Plan) Benefits Overview for 2016

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 07/25/2016

Medicare Part D helps to cover the costs of your prescription drugs. Medicare-approved private insurance companies offer Medicare Part D Prescription Drug Plans. If you have Medicare Part A and/or Medicare Part B, you are eligible for Medicare prescription drug coverage. You can get this coverage in the form of a Medicare Advantage Prescription Drug plan (MAPD) or a stand-alone Medicare Part D Prescription Drug Plan. You can enroll in any of the Medicare Part D Prescription Drug Plans that serve the area where you live. Our easy-to-use Medicare Part D Comparison Tool can help you compare and choose a plan.

The Annual Election Period (or Fall Open Enrollment) for Medicare Part D Prescription Drug Plans lasts from October 15 to December 7 every year. During this time period, anyone with Medicare can enroll in a Medicare Part D Prescription Drug Plan or change from one plan to another.

You can enroll in a Medicare Prescription Drug Plan or change plans anytime if you qualify for Extra Help with your prescription drug costs. Extra Help (also known as the Low-Income Subsidy) is a program that helps beneficiaries with limited income with Medicare Part D costs. Depending on your level of Extra Help, this may include monthly plan premiums, copayments, and deductibles (see below for more information on eligibility requirements).

You may also be able to join, switch, or drop Medicare Prescription Drug Plans during a Special Election Period, which may occur any time of the year that you have a qualifying situation. Some situations that may qualify you for a Special Election Period include (but aren’t limited to) when you move out of a plan’s service area or if you live in a nursing home or other assisted-care institution. Eligibility for the Extra Help program is another situation that qualifies you for a Special Election Period.

What should I consider when choosing a plan?

  • Costs: Medicare Part D costs can vary by plan and may include premiums, copayments, coinsurance, and deductible expenses. eHealth’s Medicare Part D Comparison Tool can also help you compare annual costs, based on the drugs you take.
  • Preferred pharmacies: Some stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans have preferred pharmacies you can use to pay lower cost sharing. If a pharmacy you use isn’t in the plan’s preferred network, you may have higher copayments and coinsurance costs.
  • Travel: Are my drugs covered if I travel (or live part-time) in another state? If you are part of a Medicare Advantage Prescription Drug plan and get your Medicare Part D coverage as part of this plan, you should make sure that your plan provides coverage in the other state. In some cases, you may have to pay higher cost-sharing amounts when you obtain prescriptions out of the plan’s network.

What are my Medicare Part D Prescription Drug Plan coverage costs?

  • Premium: You pay a monthly premium for a Medicare Part D Prescription Drug Plan, which varies depending on your state, insurance company, and particular plan. The national base beneficiary premium in 2016 is $34.10 per month.
  • Deductible: No Medicare Prescription Drug Plan can have a deductible higher than $360 in 2016. However, your actual deductible will depend on your location, the insurance company you use, and the particular plan you choose. Many plans do have a deductible, and you usually pay all of your drug costs up to that amount. Some plans do not have a deductible (called $0 deductible plans), but these plans typically have higher premiums or higher copayment and coinsurance amounts.
  • Initial coverage stage: Once you reach the deductible amount, you pay a copayment or coinsurance in the initial coverage stage until your total drug costs (what you pay, plus what your plan pays) reach the coverage gap, which is $3,310 in 2016. The Medicare Part D coverage gap is also called the “donut hole.”
  • Coverage gap: The coverage gap begins once you leave the initial coverage stage and ends when you spend a total of $4,850 out of pocket in 2016. If you reach the gap in 2016, you pay 45% of your plan’s cost for covered name-brand prescription drugs and 58% of your plan’s cost for covered generic drugs. Under the Affordable Care Act provisions, there will be additional discounts in the coverage gap each year through 2020, when the coverage gap will be closed entirely, and you will have continuous Medicare Part D prescription drug coverage.
  • Catastrophic coverage: Once you have reached the out-of-pocket limit in the coverage gap, you qualify for catastrophic coverage. You pay only a small copayment or coinsurance for covered drugs for the remainder of the year in this stage. Only a small percentage of beneficiaries reach the catastrophic coverage stage each year.

Does Medicare provide extra help for my Medicare Part D Prescription Drug Plan costs?

Yes, if you are in a Medicare Part D Prescription Drug Plan and qualify for assistance, you can get Extra Help from Medicare to pay your monthly premiums, yearly deductibles, and prescription copayments. The amount of help you receive will depend on your income and resources.

To qualify for the Extra Help program, you must:

  • Live in one of the 50 states or the District of Columbia.
  • Meet the annual income and resource limits, which can change from year to year.

Depending on your income and asset levels, you may be eligible for either full or partial Extra Help. You can contact Social Security (contact information is below) for the most up-to-date eligibility information and to see if you qualify. You automatically qualify for Extra Help if you have any one of the following:

  • You have complete Medicaid coverage.
  • You get assistance from a state Medicaid program for paying Medicare Part B premiums as part of a Medicare Savings Program.
  • You get Supplemental Security Income (SSI) benefits.

If you automatically qualify for Extra Help because of one of the above situations, you do not have to submit an application to apply. Medicare will mail you a purple-colored notice to let you know that you automatically qualify for the program. Once you find out that you qualify, you should enroll in a stand-alone Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, if you do not already have Medicare Part D coverage. Remember, if you have Extra Help, you can enroll in Medicare Part D at any time with a Special Election Period. If you don’t enroll in a Medicare Prescription Drug Plan, Medicare will automatically enroll you in a plan.

Even if you don’t automatically qualify for Extra Help, you may still apply. If you think you may qualify for Extra Help, you can:

  • Call Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. TTY users can call 1-800-325-0778.
  • Visit the Social Security website (www.socialsecurity.gov).
  • Go to your local Social Security office to apply in person.
  • Apply at your state Medical Assistance (Medicaid) office.

What drugs are not covered?

There are certain drugs or categories of drugs that the Medicare program does not cover. These are called excluded drugs; some Medicare Part D Prescription Drug Plans may include these drugs as an added benefit.

The Centers for Medicare & Medicaid Services (CMS) does not require these categories of drugs to be covered:

  • Weight loss or weight gain
  • Fertility
  • Cosmetic (e.g., hair growth)
  • Cough and cold
  • Non-prescription drugs
  • Over-the-counter smoking cessation (prescription smoking cessation drugs are covered)
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

Considering adding a Medicare Part D Prescription Drug Plan to your coverage, or switching the plan you have now? I can help you evaluate the different plan options available to you.

  • Check out my profile with the “View profile” link below if you’d like to know more about my background.
  • To get some more Medicare plan information to review, use the links below; you can schedule a phone call with me or have me email you plan options.
  • If you’d like to compare some of the Medicare plans that could cover your medications, use the Compare Plans buttons on this page.
  • Need some help right away? Call Medicare.com’s licensed insurance agents at 1-844-847-2659, TTY users 711; Monday through Friday, 8AM to 8PM ET.

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