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Medicare Part D: What You Need to Know

November 22, 2021

If you’re enrolled in Medicare or considering enrolling in a program before the deadline of December 7, it’s important to understand factors that could affect your prescription drug coverage, also known as Medicare Part D. Medicare Part D is one of four parts within Medicare, the public health insurance plan for those aged 65 and older or those with end-stage renal disease or Lou Gehrig’s disease, also known as ALS. In addition to Part D, Medicare also includes Parts A and B (Original Medicare) and Part C (Medicare Advantage).

Part D plans, also known as Prescription Drug Plans, are offered by private companies to complement Original Medicare plans. Though Part D plans require separate enrollment from Original Medicare, Part D plans may lower costs for prescription drugs and offer greater access to medication. Types of plans available for prescription drug coverage include standalone Medicare Part D Prescription Drug Plans (PDP) plans or Medicare Advantage plans that include Part D drug coverage.

When considering a Part D plan or a Medicare Advantage plan that includes Part D coverage, there are important factors to consider. For example, all Part D plans are required to cover a broad range of drugs, but not all plans cover the same drugs and the plans can vary by cost. Costs and coverage can change from year to year, so it’s important to review the information even if you’re already enrolled – especially for those with a chronic or serious illness.

Here are a few key factors to consider when evaluating plans for prescription drug coverage:

  • Formularies: Each plan has a list of drugs it will cover, called a formulary, including both brand name and generic drugs. All plans must cover at least two drugs per drug category, and these coverages can change year to year.
  • Donut hole coverage gap: Many Medicare Part D plans have a coverage gap, known as the donut hole. This means that the plan has a temporary limit on what it will cover for Medicare. Make sure to review the donut hole to ensure medications you need are covered.
  • Coverage tiers: Many plans have tiers of drugs with different levels of coverage and co-pays for each tier. Plans can divide their tiers in different ways. Generally, the lower the tier, the lower the co-pay. If you take generic drugs, this could be beneficial because certain tiers have no or low-cost copayments.
  • Needs and costs: Consider what your needs are now and what they could be in the future. Choose a plan that best fits your anticipated needs for the coming year, and remember that you can change plans during open enrollment each year.
  • Plan restrictions: Some Medicare Advantage plans can restrict which hospitals, doctors, and pharmacies you use under the plan. Doctors and pharmacies within the same organization are not guaranteed to be covered by the same plan, so it’s best to confirm before enrolling.

The Medicare open enrollment period closes on December 7. To find information, compare plans, find drug formularies, and to review any restrictions, visit Medicare.gov. A handy list of plans accepted by Texas Oncology, categorized by medical and pharmacy coverage, is available.

For more information, visit Texas Oncology Pharmacy Services.

For upcoming webinars visit www.TexasOncologyFoundation.org.