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Prescription drug coverage
There are 2 ways to get prescription drug coverage through Medicare, either by a stand alone Drug plan or through a Medicare Advantage plan with drug coverage. To get Part D you must have and/or be eligible for Part A and B. Prescription drug plans cover drug purchased through a retail pharmacy or mail order pharmacy.
Like Part B, there is a penalty for not taking Part D when first eligible. That penalty is 1% per month you go w/o a drug plan until you enroll in one for the average cost of a drug plan (Approx. $35.00 monthly).
**Example not enrolled for 12 months .35 x 12 = $4.20.
Also, the IRMAA applies to Part D as well, get the upcharges here. View IRMAA
All Part D drug plans have to follow rules set by Medicare. RX Plans have to carry 2 drugs minimum in each family of their formulary* for a particular condition. All Part D plan are subject to various "Enrollment Periods" For a list click here. Every drug plan works on a tiered system of pricing there are up to 6 tiers to drug plans available in our area.
Drug Plan Tiers:
- Tier 1 is Preferred Generic
- Tier 2 Non-Preferred Generic
- Tier 3 Preferred Name Brand
- Tier 4 Non-Preferred Name Brand
- Tier 5 Specialty Drugs (Medicare defines any drug for which the negotiated price is $670 per month or more, as a specialty drug which is placed in a specialty tier that requires a higher patient cost sharing.)
- Tier 6 drugs are available on select drug plans.
Every Drug Plan has 4 "Stages" works on a calendar year.
- Deductible (if applicable) once you pay the deductible you go to the Initial Coverage Stage
- Initial Coverage Stage, after you paid the deductible then you pay a straight co-pay/co-insurance for your drugs up to a retail cost limit of $4330.00 for 2022 / $4,660.00 for 2023.
- Coverage Gap (donut hole) once you've exhausted the $4330.00 retail cost limit in the Initial Coverage Stage you go into the Coverage Gap (donut hole) and will pay 25% of the costs for name brand drugs and 25% of the costs for generics until you hit another retail cost limit of $7,050.00 for 2022 / $7400.00 for 2023. After reaching $7,050.00 you move into the Catastrophic Coverage for the remainder of that calendar year.
- Catastrophic Coverage In this stage you pay $3.95 in 2022 / $4.15 for 2023 for generics and $9.85 in 2022 / $10.35 in 2023 for name brand drugs or 5%.
*It is very important that you do and annual review of your prescription drug plan as the plan can change drugs in and out of a formulary and once December 7th passes you are locked into the plan you are on until next open enrollment (October 7th thru December 7th)