Medicare Part D

Medicare Part D

The Medicare program, which is a federal program that helps senior citizens and certain other individuals pay for health care, is divided into four parts. Part A covers hospital and inpatient services and Part B covers doctor visits and other outpatient services. Together, Parts A and B are referred to as original Medicare. Part C, also known as Medicare Advantage, makes Medicare-covered services available through private health plans, such as HMOs, PPOs, and private fee for service plans (PFFSs). Part D prescription drug coverage is offered by private companies through stand-alone plans (for members who have original Medicare) and through HMOs, PPOs, and PFFSs (for beneficiaries who have Medicare Advantage). Anyone who has original Medicare or Medicare Advantage is eligible to enroll in Part D. Enrollment in Part D is voluntary.

In General:

Private companies that offer Part D coverage are allowed to design their own benefit plans, as long as the overall value of the plan is at least as good as the basic plan outlined in the 2003 Medical Act. So, different plans offer different lists of medicines (called a formula), and different costs. Beneficiaries should compare the different drug plans available in their area to find the one that best suits their needs.

The Basic Plan:

The basic plan generally meets the following criteria:

The annual deductible can’t be more than $320 (in 2015)
The plan must cover at least two drugs in each drug class
The plan must cover substantially all drugs in these six categories: antidepressants, anti-psychotics, anticonvulsants, antiretrovirals (AIDS treatments), anticancer drugs, and immuno-suppressants
Members must be able to seek an exception if a drug is medically necessary but not covered under the plan
Plans must have a network of pharmacies that provide convenient access
Lists of covered drugs and pharmacy networks must be readily available to members
Plans must work with nursing homes
Plans must help transition a member’s current drug coverage
Plans must offer catastrophic coverage

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