Medicare Part D: Understanding the basics

Unpacking Medicare means learning about all the different Medicare parts. We recently wrote about the basics of Medicare, including the four parts. The ApexHealth team gets asked a lot of questions about prescription drug coverage, so we want to help you better understand Medicare Part D.

How do I get Part D prescription drug coverage?

Original Medicare (Parts A and B) and Medigap plans do not include prescription drug coverage. This means you can get coverage in one of two ways – as a standalone Part D plan (PDP plan) or a Medicare Advantage plan with Part D coverage (MAPD plan).

Both MAPD plans and PDP plans are offered by private health insurance companies.

What drugs does Part D cover?

Part D covers certain prescription drugs, but it does not cover drugs covered by Original Medicare (Parts A and B) or drugs that are excluded by Medicare. Examples of these drugs include those used to treat anorexia, weight loss, or weight gain, fertility drugs, drugs used for cosmetic purposes, prescription vitamins and minerals (with some exceptions) and nonprescription drugs (over-the-counter drugs).

The federal government requires that certain common types of drugs be covered by Medicare Part D. These include at least two drugs from most drug categories (a group of drugs to treat the same symptom or have similar effects on the body) and all (or substantially all) available drugs in the following categories: anticancer drugs (that aren’t covered by Part B), anticonvulsive treatments, antidepressants, antipsychotics, HIV/AIDS treatments and immunosuppressant drugs (for prevention of organ transplant rejection). After that, individual plans can choose what drugs of each type they will cover – both generic and brand name.

If you’re wondering what prescriptions are covered by ApexHealth MAPD plans, we try and keep it very easy for you! Visit our online search tool to find covered prescriptions and pharmacies. Or call (844) 279-0508 and ask an ApexAssistant to do the searching for you!

What vaccines does Part D cover?

Commercially available vaccines that are not covered by Medicare Part B are covered under Medicare Part D as long as they’re deemed reasonable or necessary to prevent illness. These include vaccines for Measles, Mumps, and Rubella (MMR), shingles and Tetanus, Diphtheria, Pertussis (Tdap). You can find out what vaccines your plan covers by looking at your plan’s formulary (list of covered drugs). Remember that Medicare Parts A and B cover the influenza, pneumococcal, hepatitis B and COVID-19 vaccines. (We wrote about this in a previous blog post.)

How much does Part D cost?

Part D costs vary based on factors such as plan, provider and location. Your costs may include coinsurance, copayments and deductibles. Both Part D and MAPD plans organize their formularies in a tiered format. Generic drugs will usually be on a lower tier and will cost less than a brand name drug.

Do I need Part D prescription drug coverage? (And when should I enroll?)

We recommend that you enroll in Part D or an MAPD plan when you first get Medicare. Delaying Part D enrollment could mean that you face gaps in your coverage or enrollment penalties. An exception would be if you have creditable drug coverage which is deemed as coverage as good as or better than basic Medicare Part D benefits (e.g., through your employer.) This can get a little tricky, though. Your employer needs to inform you annually whether or not their prescription drug coverage is creditable.

Remember, if you enroll in Part D late, you’ll have to pay a Part D late enrollment penalty, which is one percent of the “national base beneficiary premium” (i.e., the average Part D premium for a given year) times the number of months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your Part D premium. Generally, you pay this penalty for as long as you have Part D.

Can I apply for help to pay for prescription drugs?

There is a federal program called Extra Help that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage. It is also known as the Part D Low-Income Subsidy (LIS). Whether or not you qualify for a full subsidy, or a partial subsidy depends on your income and assets, and, if you qualify, you can receive the LIS benefit if you are enrolled in an MAPD plan like ApexHealth.

When can I change my Part D coverage?

In most cases, you’re only able to make changes to your Part D coverage during Medicare’s Annual Election Period (AEP) which takes place every fall from October 15 through December 7. Your choice takes effect on January 1 of the following year. Under special circumstances, you may be eligible for what’s known as a Special Enrollment Period (SEP), a time outside of open enrollment when certain events happen permitting you to make changes to your Medicare coverage. (There are a few rules, so take look at what the Centers for Medicare and Medicaid Services (CMS) has to say.)

If you have any questions or would like help understanding Medicare Part D prescription drug coverage, feel free to reach out. Give us a call at (844) 279-0508 (TTY: 711). Our hours of operation are Monday through Friday 8 a.m. – 8 p.m. (local time) from Apr. 1 through Sept. 30 and seven days a week 8 a.m. – 8 p.m. (local time) from Oct. 1 through Mar. 31.

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