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Health Insurance Basics

Learn the Basics About Medicare Part D Drug Coverage

August 30, 2017

Did you know Original Medicare does not cover most prescription drugs you buy at a pharmacy? That’s why it’s important to get benefits from a private insurer through a stand-alone  Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug benefits.

Prescription Drugs and Medicare Part D Coverage

All Part D drug plans must give at least a standard level of Medicare benefits to make sure plan members can get medically necessary drugs to treat their conditions. And every Medicare prescription drug plan has its own specific list of medications that are covered, which is known as a formulary. While each drug list is unique, they all have some things in common:

  • Plans cover both generic and brand-name prescription drugs.
  • The drug list must include a range of drugs in the most commonly prescribed categories and classes.
  • Although one of your specific medications might not be included, a similar drug should be available.

It’s possible your plan might make some changes to its drug list during the year because drug therapies change, new medications are released, and new medical information becomes available. If the change involves a drug you’re currently taking, your plan is required to give you written notice at least 60 days before the date the change becomes effective. Or when you request a refill, they can give you written notice and a 60-day supply of the drug under the same plan rules that applied before the change.

Medicare Part D Drug Coverage Organizes Drugs by Tiers

To help keep your costs down, most prescription drug plans have different “tiers” or levels of cost. Most tiers are arranged so that a drug in a lower tier costs less than a drug in a higher tier.

Typically, there are three to six tiers. Here’s an example of four-tier Medicare drug benefits:

  • Tier 1: Most generic prescription drugs, with the lowest copay level.
  • Tier 2: Preferred, brand-name prescription drugs, with copays in the midrange.
  • Tier 3: Non-preferred, brand-name prescription drugs that have a higher copay.
  • Tier 4 or Specialty Tier: Unique, very high-cost medications, with the highest. copays or coinsurance that requires you to pay a percentage of the cost.
More Things to Keep in Mind About Medicare Part D Coverage

In addition to drug lists and tiers, there are some rules that plans use to make sure certain drugs are used correctly and only when medically necessary. These help keep costs down and ensure your safety:

  • Preapproval - Your doctor may need to contact your plan before writing a prescription to confirm that the drug is medically necessary and appropriate for your condition.
  • Step therapy - If more than one medication can do the same thing for your condition but at different costs, your doctor will prescribe a less expensive drug first. Then you can “step up” to more a more expensive drug if that one isn’t working.
  • Quantity limits - Your plan may limit the amount of some drugs you can get at one time. If you refill a prescription too soon, or if you’re prescribed an amount above safety standards, your doctor may need to contact the plan before you can refill your prescription.

If your plan doesn’t cover a prescription your doctor says you need, you do have the right to ask for an exception. Usually your doctor will need to submit a written statement that explains the medical reason for the request, such as why similar drugs covered by your plan won’t work for you or why a coverage rule, like step therapy, should be waived.

Remember, Original Medicare benefits do not include all the prescription drug coverage you probably need. Now that you know how Medicare Part D drug coverage works, you can compare plans and choose one that best covers your current medications and helps protect your health.

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Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., is an HMO with a Medicare contract. Enrollment in Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. depends on contract renewal. Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. is a D-SNP plan with a Medicare contract and a contract with the Georgia Medicaid program. Enrollment in Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. depends on contract renewal. Blue Cross and Blue Shield of Georgia, Inc. is an LPPO plan and a PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of Georgia, Inc. depends on contract renewal. Blue Cross and Blue Shield of Georgia, Inc., and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem Insurance Companies Inc. (AICI) has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer Medicare Prescription Drug Plans (PDPs) noted above or herein AICI is the state-licensed, risk-bearing entity offering these plans. AICI has retained the services of its related companies and authorized agents/brokers/producers to provide administrative services and/or to make the PDPs available in this region. Blue Cross and Blue Shield of Georgia, Inc. and AICI are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Blue Cross and Blue Shield of Georgia, Inc., is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

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