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What Happens When You Do Not Have a Part D Prescription Drug Plan?

Written by David Maxwell

If you are age 65 or older, then you may be familiar with the coverage that is provided through Medicare. This program, which began back in 1965, is a federal program that offers coverage for hospitalization, as well as for doctors’ services and necessary medical equipment.

When it initially began, Medicare consisted of Part A and Part B.

These two parts of Medicare are often referred to as Original Medicare. With Part A, Medicare provides coverage for a wide range of hospitalization services, as well as some limited coverage for care that is needed in a skilled nursing facility, and some limited hospice and in-home care services.

Medicare Part B offers coverage for visits to your doctor, as well as certain preventive services, the cost of clinical research studies, and for durable medical equipment (DME) that is prescribed for your condition by your doctor.

medicare drug planWhile prescription medication is not covered directly in Medicare Part A or Part B, it is possible for those who are enrolled in Original Medicare to purchase a stand-alone prescription drug plan through Medicare Part D.

If a Medicare enrollee has instead opted to receive their Medicare Part A and Part B coverage through a Medicare Advantage plan – which is also known as Medicare Part C – then prescription drug coverage may automatically be included in the Part C plan.

What Is Medicare Part D And What Does It Cover

Unlike Medicare Parts A and B, Medicare Part D – which covers prescription medications – is not offered directly through Medicare itself. Rather, Medicare Part D plans are offered via independent insurance carriers that are approved by Medicare for offering these plans.

Because Medicare Part D is provided by many different insurance companies, the coverage that is provided – as well as the premium that is charged – can differ, sometime substantially, from one plan to another, and from one insurance company to another.

The prescription medication coverage that is provided by Medicare Part D plans will be based on the plan’s formulary – which is each plan’s list of covered medications. With that in mind, if you move forward with the purchase of a Medicare Part D plan, it will be important for you to ensure that the medicines you take are listed in the particular plan’s formulary.

There are also various “tiers” of prescription medication coverage. For example, a medication that is included in a lower tier will typically cost less than a medication that is included in a higher tier. (In some cases, though, if your medical professional believes that you require a medication that is listed in a higher tier, you may be able to obtain an exception in order to get a lower amount of required copayment).

For you to obtain Medicare Part D’s prescription medication benefits, your plan will require the following:

  • Prior Authorization – In this case, you and/or your prescribing medical professional will need to contact the drug plan before filling various prescriptions. It may be required that your doctor show proof that the medication is medically necessary in order doe the plan to provide coverage.
  • Limit on Quantity – There are also limitations on the amount of prescription medication that you are able to receive at any one time.
  • Step Therapy – It may also be necessary that you try one or more similar, lower cost medications before your plan covers the prescribed drug.

There are certain items that are required for a Medicare Part D plan to cover – regardless of where it is purchased. For example, other than the preventive vaccines that are covered under Medicare Part B, a Medicare Part D prescription drug plan is required to cover all commercially available vaccines, such as the vaccine for shingles, when they are considered to be medically necessary for the prevention of illness.

What Exactly Is The Medicare Part D Donut Hole?

Many of the Medicare Part D plans that are offered will have a coverage “gap” – which is also often referred to as the Medicare Part D donut hole. This means that there will be a temporary limit on what the plan will cover for prescription medications.

While not everyone who is enrolled in Medicare Part D will experience a coverage gap, it is important to know whether or not you could be. The coverage gap will begin after you, and your Part D drug plan have spent a certain amount on covered medications. In 2017, this amount is $3,700. Once you have spent this much on your medications, you will be in the coverage gap.

If you are in the coverage gap, or donut hole, it may be possible to obtain a discount on your drugs after the coverage has kicked in. You might be able to save money on brand-name prescriptions.

How Can You Get A Medicare Part D Prescription Drug Plan

For those who are enrolled in Medicare Part A and B (Original Medicare), you can purchase a separate Medicare Part D plan if you wish to also obtain coverage for the medications that you need.

In searching for the best Part D plan for you, it is a good idea to compare the offerings of many different insurance carriers – as well as the premiums that are charged – prior to making your final purchase.

If you have opted to obtain your Original Medicare (Medicare Part A and Part B) coverage via a Medicare Advantage plan (or Medicare Part C), it is possible that prescription medication coverage will be already automatically included in your plan. Therefore, you won’t also need to purchase a separate, stand-alone Medicare Part D plan.

How Much Does Medicare Part D Prescription Drug Coverage Cost?

In addition to the premium that you pay for Medicare Part D prescription drug coverage, these plans will also oftentimes have additional expenses as well. For example, you will usually incur an annual deductible amount, after which your Part D coverage will begin.

Although the amount of your deductible may differ from one insurance carrier to another, there are no Part D plans that are allowed to have a deductible of more than $400 in 2017. It is also possible that you could purchase a Medicare Part D plan that does not have any deductible at all.

What Happens When You Do Not Have A Part D Prescription Drug Plan?

If you do not have a Medicare Part D plan, it may be possible to obtain your prescription drug coverage from other sources. For example, if you are still working and you are part of an employer-sponsored health insurance plan, it is possible that some or all of your medications will be covered. Likewise, if your spouse is still employed and he or she has prescription drug coverage, you may be eligible to enroll in this plan, too.

It is important to understand that if your current prescription drug coverage expires due to retirement or other factors, you will need to enroll in a Medicare prescription drug plan within a certain period of time. Otherwise, you risk having to pay a penalty when you do enroll.

For example, if you wait to enroll in Part D coverage past your initial eligibility, and you do not have “creditable coverage” – which is coverage that is as good as Medicare standard drug coverage – then you may be required to pay a Medicare Part D late enrollment penalty. The amount of this penalty will be based on the length of your delay in Part D enrollment. And, the penalty will be added to your monthly Medicare Part D premium for as long as you have the Part D prescription coverage. Therefore, it could make your coverage much costlier for you – especially over a long period.

How To Help Reduce Your Medicare Out-of-Pocket Costs

If you are enrolled in Original Medicare, and you want to help yourself in reducing your out-of-pocket costs on copayments, coinsurance and / or deductibles, one of the best ways to do so is to enroll in a Medicare Supplement plan.

Medicare Supplement – also known as Medigap insurance – is a type of insurance protection that is specifically designed for helping enrollees with the cost of expenses that are not covered by Medicare.

Currently, there are ten different Medicare Supplement insurance plans to choose from – and each of these is named after a certain letter of the alphabet. Depending on the specific Medicare Supplement plan that you choose, you may be able to reduce or eliminate out-of-pocket responsibilities such as your:

  • Medicare Part A deductible
  • Medicare Part B deductible
  • Coinsurance that is required for a stay in a skilled nursing home facility
  • Expenses that you incur for health care if you are traveling in a foreign country

In some cases, you may also be able to reduce your overall health care costs by enrolling in a Medicare Advantage plan. Medicare Advantage offers an alternate way of receiving your Medicare Part A and Part B benefits, and many of these plans will also include coverage for prescription medications. So, if you are purchasing you Medicare coverage through a Medicare Advantage plan, and you want to also have prescription drug coverage, be sure to inquire as to which of your options will include this coverage.

Find The Best Premium Rates On Medicare Supplement And Medicare Advantage Plans

As you’re looking for the lowest rates on MA and Medigap plans your search will normally lead you to an actual carriers website where you’ll only get a quote from them. This route leaves you vulnerable to paying higher rates because you’ve skipped out on comparing companies!

Since we are independent agents we have the ability to give you quotes from as many companies as you want! However, we will package the top few in a nice comparison chart so that your decision is simple and easy. So if you are ready to take a look at the Medicare-related coverage options that are best fit for you, just simply use the quote form on our site.

Should you still have any additional questions regarding Medicare Part D prescription drug coverage, Medicare Advantage, Medicare Supplement – or any other Medicare or insurance related question – please feel free to call us directly, toll-free, at 864-332-4209.

Making sure that you have the best Medicare coverage for your needs can be confusing. But, the process can be made much easier when you are working with an expert in the field. So, contact us today, we’re here to help.

About Growth 360, LLC
About Growth 360, LLC

We work with individuals across the nation to secure the best Medicare Supplement rates.

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