Medicare Part D is the prescription drug coverage arm of Medicare. Original Medicare focuses on inpatient hospital care and doctor visits under Part A and Part B, but it does not include any prescription drug coverage. It can be critical to enroll in Part D for medications that are prescribed by your doctor, you purchase at a pharmacy, and take at home. Medicare Part B can help cover medications administered in a doctor’s office or outpatient setting.
Part B Drug Coverage
Part B provides outpatient prescription drug coverage with specific limitations. This applies mostly to drugs that patients would not typically self-administer. Instead, the solution would be dispensed by a healthcare practitioner in a doctor’s office or hospital outpatient facility. In some cases, recipients are given instructions on how to inject or infuse the drugs on their own, presided over by a licensed medical professional.
These include drugs used with durable medical equipment (DME), certain antigens, injected osteoporosis drugs, erythropoiesis-stimulating agents, blood clotting factors, treatment for oral end-stage renal disease (ESRD), nutrition through intravenous or tube feeding, intravenous immune globulin, vaccinations and transplant/immunosuppressive remedies, among others. The circumstances under which these drugs are covered are quite specific. The patient will usually pay for their annual deductible and 20% of the amount approved by Medicare.
Part D Prescription Drug Coverage
A formulary is a tiered list of covered drugs. Each prescription drug plan has its own formulary, and costs and coverage can vary from plan to plan. Check with your Part D to check on specific drugs. Drugs may shift to different tiers, which has a direct impact on your cost. Drugs may also be removed from coverage or replaced with similar medications. For these reasons, it is a good idea to review the formulary at least annually to validate the status of your prescribed medications.
Some plans impose rules that limit drug coverage. Be familiar with the rules to ensure adherence and avoid jeopardizing your benefits. Following are examples:
- Coverage of only medically necessary drugs.
- Limits imposed on the quantity purchased each time.
- Step therapy that requires you try lower-cost alternatives before a high-end drug is covered.
- Safety checks established to avoid drug interactions and dosage errors, gaining much attention now with the rising opioid epidemic.
The Right of Appeal
Medicare recipients have the right to appeal drug coverage decisions. A written explanation of the decision is known as a coverage determination. With support from your medical provider, you may submit a formal request for an exception to a rule. Examples of exception requests may be to cover a drug prescribed for your ailment that is not currently included in the formulary or to waive a requirement to use a lower-tier drug that does not resolve your health condition.
If you are enrolled in a drug plan that is not providing the coverage you need, you have the opportunity to apply for another plan every year during the Annual Enrollment Period of October 15 to December 7. If you enroll before the deadline, the change will be effective January 1 of the following year.