May 27, 2019 How-To

Understanding Medicare Part D

Medicare plans include a standard level of coverage, and that goes for prescription drug coverage, too. Every Medicare Advantage plan must cover all services available with Original Medicare coverage. When it comes to Medicare Part D, though, you may come across variations with respect to which pharmacies the plans use, which drugs are covered, and how much they cost.

Plans use different methods to determine prescription drug coverage based on network pharmacies, prescription drug formularies, and other coverage rules.

How Part D Coverage Works

Medicare Part D drug plans have contracts with network pharmacies, which you must use to ensure that your prescriptions are covered.

Part D drug coverage is based on a formulary that’s regularly reviewed and updated by pharmacy and medical professionals. Drugs on the formulary are organized into tiers, and your copayment or coinsurance depends on the tier your medications are in.

Ask your physician or health care provider whether a generic form of your prescription is available. Generics are just as effective as brand-name drugs and are more economical.

For your added convenience, mail-order programs enable you to obtain a 90-day supply of your prescription medications that’s delivered directly to your home. This is a cost-effective and handy way for many Medicare members to get their prescriptions. If you have a CDPHP Medicare Advantage plan with prescription coverage, check out our mail-order service.

Part D Guidelines

To ensure that prescription drugs are used correctly and appropriately, rules that include prior authorization, step therapy, and other limitations on the quantity of drugs that a patient can receive at a time are in place.

Prior authorization requires that your prescriber contact the plan before prescribing a drug to confirm that it’s medically necessary.

Step therapy is similar to prior authorization. It requires Medicare members to try the least expensive drugs first before moving to a more expensive option. These lower-cost drugs have been proven effective for most people with a particular condition. For example, your plan might require you to try a generic prescription drug before a less expensive brand-name drug on its preferred list. If neither works, or if you have any adverse effects, the plan will likely cover a similar, more expensive brand-name prescription drug.

If your prescriber believes that the more expensive brand-name drug is the best option for your condition, she or he may contact your Medicare plan to request an exception. If approved, your Medicare plan will cover the step therapy drug.

Medication Therapy Management

When applying for Medicare, keep in mind that you can take advantage of a medication therapy management program, which helps ensure that your medications are working properly together to improve your overall health. You will have a discussion with a pharmacist or health professional to determine how you can get the most out of your medications, your concerns (like costs or adverse effects), and any questions about your prescription or over-the-counter medications.

Following this discussion, you will receive a written summary that includes an action plan for you to follow so you can optimize your medication management. It might be worthwhile to schedule a medication review prior to your yearly physical so that you can discuss it with your physician at the visit.

Don’t Forget that Medicare Open Enrollment Ends December 7

You have a few options for applying for Medicare and Part D coverage, including online or by mail, fax, or phone. Once you’ve found the right plan for your life, health, and budget, Medicare enrollment is easy! Questions? Call us today!


Photo by Mike Mozart / CC BY

Alicia Kelley
About the Author

Alicia joined CDPHP in 2005 and is currently Vice President, Medicare Performance. In this role she is responsible for the growth, retention and oversight of the operational administration of our Individual Medicare Advantage plans. Prior to working at CDPHP, Alicia worked as a Facilitated Enrollment Specialist for Healthy Capital District Initiative, a local not-for-profit, assisting community members in obtaining access to Medicaid, Family Health Plus, and Child Health Plus. She received her bachelor’s degree in Political Science from Siena College, with a minor in Sociology.

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