Medicare Part D: how to check if your drug plan still fits

For many people with Medicare, prescription drugs are the most unpredictable part of the yearly budget.

A plan that was a good match last year can become expensive without any warning that looks obvious.

A medicine moves to a higher tier, a pharmacy leaves the preferred network, or a new prescription is added after a doctor's visit.

Medicare drug coverage, known as Part D, is sold by private companies under federal rules, and those companies can change their plans every year.

This guide explains how Part D works, what changes from one year to the next and how to check whether your plan still fits.

It applies whether you have a stand-alone drug plan alongside Original Medicare or drug coverage built into a Medicare Advantage plan.

obeneficiado is an independent information site.

We are not Medicare, we do not sell plans and we do not receive anything for the plan you choose.

How a Part D plan decides what you pay

Every drug plan has a formulary, which is its list of covered drugs.

A medicine that is not on the list is generally not covered, unless the plan grants an exception.

Drugs on the formulary are grouped into tiers. Lower tiers usually hold generic drugs with small copays;

higher tiers hold brand-name and specialty drugs with higher copays or a percentage of the price, called coinsurance.

Plans can also have a yearly deductible, which you pay before the plan starts sharing the cost, and a network of pharmacies.

Preferred pharmacies usually charge less than standard ones in the same plan.

Some drugs come with rules such as prior authorization, step therapy, where you try a cheaper drug first, or limits on the quantity per prescription.

What changes from one year to the next

• The monthly premium and the deductible
• Which drugs are on the formulary
• The tier of each drug, and therefore its copay
• Which pharmacies are preferred, standard or out of network
• Rules such as prior authorization or quantity limits

Your plan must list these changes in the Annual Notice of Change it sends by September 30.

That letter is the starting point of any review.

Protections that already exist in the law

Federal law now places a yearly cap on what you pay out of pocket for covered Part D drugs.

Once you reach it, you pay nothing more for covered drugs for the rest of that calendar year.

The amount is adjusted every year, and the current figure is published on Medicare.gov.

Covered insulin costs no more than 35 dollars for a one-month supply, and vaccines recommended for adults,

such as the shingles vaccine, are covered at no cost under Part D.

There is also the Medicare Prescription Payment Plan,

which lets you spread your drug costs into monthly payments across the year instead of paying large amounts at the pharmacy counter early in the year.

You ask your plan to join it.

Extra Help for people with limited income

Extra Help is a federal program that helps pay Part D premiums, deductibles and copays for people with limited income and resources.

Many people who qualify never apply.

You can check the rules and apply through the Social Security Administration, and people who receive Medicaid or certain other benefits usually get it automatically.

A simple way to check your plan

1. Gather the exact name, dose and frequency of every drug you take.
2. Open the official Medicare Plan Finder and enter your ZIP code, your drugs and your usual pharmacy.
3. Look at the estimated total yearly cost of your current plan for next year.
4. Compare it with the two or three cheapest plans on the list.
5. For each one, confirm that every drug is covered and check for prior authorization or quantity limits.

The yearly total is the number that matters.

A plan with a low premium and a high deductible can cost more than a plan with a higher premium that covers your drugs on lower tiers.

If your drug is not covered

A missing drug is not always the end of the conversation.

You or your prescriber can ask the plan for a coverage determination,

and request an exception if you need a drug that is not on the formulary or need it at a lower tier.

Your doctor usually has to send a statement explaining why the alternatives on the list would not work for you.

The plan must answer within a set deadline, and faster when waiting could seriously harm your health.

If the plan says no, you have the right to appeal.

The written decision must explain the reasons and the next steps, and Medicare.gov describes each level of the appeal process.

Another option is to ask your doctor whether a generic or a similar drug on a lower tier would work just as well for you.

That single conversation often lowers the bill more than switching plans does.

Do not go without drug coverage by accident

If you go 63 days or more in a row without Part D or other creditable drug coverage after you first become eligible,

you may pay a late enrollment penalty added to your premium for as long as you have Part D.

Creditable coverage means drug coverage, such as some employer or union plans,

that is expected to pay at least as much as standard Medicare drug coverage.

Your employer or plan must tell you each year whether yours is creditable.

When you can switch

The main window is Medicare Open Enrollment, from October 15 to December 7, with the new plan starting on January 1.

Some situations open a Special Enrollment Period, such as moving out of your plan's area or qualifying for Extra Help.

If you are unsure, a free counselor at your State Health Insurance Assistance Program (SHIP) can review your situation with you.

Sources and Further Reading

• Medicare.gov — how Part D works, the yearly cap on drug costs, insulin and vaccine coverage, and the appeal process.
• Medicare Plan Finder — compare drug plans using your own prescriptions and pharmacy.
• Social Security Administration — Medicare — rules and application for Extra Help.
• SHIP National Technical Assistance Center — free, unbiased counseling in every state.

obeneficiado is an independent information site.

It is not affiliated with Medicare, the Centers for Medicare & Medicaid Services or any government agency,

and it does not sell or recommend specific insurance plans. Amounts and rules change; confirm current details on Medicare.gov.