Medicare Part D is also called the Medicare prescription drug benefit. This is because Medicare Part D plans provide prescription drug coverage to enrollees who subscribe to a Medicare plan. To receive Medicare Part D, an individual must subscribe to an insurance plan run by an insurance company or other private entity approved by Medicare. Different Medicare Part D plans may cover different drugs, so it is important to make sure the plan you choose covers the prescription medicine that you need. If you are concerned about the Medicare Part D cost, then you should be aware that late enrollment in a plan can result in a penalty that will increase the premium. However, prescription coverage may be available through Medicare Part C plans.

Learn More About Medicare Part D Coverage

All Medicare Part D plans have a list of pharmaceutical products approved for coverage on their individual plans for drug coverage. Insurance companies that provide Medicare Part D coverage refer to these lists of approved pharmaceutical drugs as formularies. Formularies typically have several tiers or levels, which pharmaceutical drugs are categorized into. The various drugs listed in the tiers of these formularies have different costs associated with them. Generally, pharmaceutical drugs that reside in higher tiers cost more than those that occupy the lower tiers of a formulary. When you enroll, the insurance company will provide you with information on what is covered by Medicare Part D coverage.

Oftentimes, the Medicare Part D cost for a name-brand drug will be higher than its generic counterpart. You or your health care provider may ask the administrator of your Medicare Part D plan for an exception if your prescription medication appears on the higher tiers of formularies. In these cases, you will need to know how to submit a Medicare claim to the provider so that you can lower your copayment on your needed medications.

Medicare Part D plans can, on occasion, alter their formularies and change the tier prescription medications may be slotted into. Medicare’s guidelines allow them to alter the formularies for Part D Medicare plans even during the course of a particular year. If changes that Medicare makes to one of its formularies affect you directly because it changes a tier for a pharmaceutical drug you are taking, then your Medicare Part D provider must do one of the following:

• Your Medicare Part D provider must notify you of the change to your prescription medication’s new tier classification no less than 60 days before the change in tier becomes active.
• At the time you make a request for a refill of your prescription medication affected by the move from one tier to another, your Medicare Part D provider must notify you in writing of the change in tiers for your prescription as well as a 60-day supply of your medication that will adhere to the rules of the plan before the change was made.

Download our free health care guide for more details on Medicare Part D coverage as well as information about Medicare’s other parts.

What are the exceptions for Medicare Part D Plans?

If you receive Medicare Part D benefits, then you are entitled to inquire about coverage of any prescription medications you feel you need that you think should be covered, provided or receive continued coverage. If the insurance company that provides your Medicare Part D plan decertifies your medication from coverage, then you may learn how to appeal their decision to stop providing or paying for the drug. You may also speak with your health care provider to see if there are any special rules with regard to the medication in question or obtain written explanations from your Medicare Part D provider in advance to ensure a drug is covered or you may ask for an exception should you disagree with their decision. Exceptions may be submitted for drugs that do not appear on your plan’s formulary but are medications you need or your approved Medicare Part D health care provider believe the rules pertaining to a particular medication need to be waived. Either you or the health care provider prescribing the medications for which you are seeking an exception must submit a request form to your plan for the exception.

Options for Enrolling in Medicare Part D

Enrolling in Medicare Part D plans is possible in two ways. You can obtain a Medicare Part D plan to compliment your Part A, Part B or Original Medicare coverage as well as look for prescription coverage through a Medicare Advantage Plan. You may find a provider by using the portal on the Medicare website to locate plans that service your area. Simply look up the Medicare Part D providers near you and contact them. You may fill out the paper enrollment form to send to Medicare to get your enrollment started. You can also call Medicare’s toll-free number to find out which plan may work best for you and to learn which providers service your area. You should also learn how enrolling in a Medicare Part D coverage option may affect any current Medicare plans you currently have. In certain circumstances, enrolling in Medicare Part D plans may unenroll you from your Medicare Part C plan.

Learn about enrolling in Medicare by downloading our free guide for seniors.