Choosing between eating or buying needed medication: it’s a story told all too often, especially among the elderly. In some cases, faced with a choice between paying the electric bill or buying their medication, they turn the heat down and put an extra blanket over their legs. They cut their pills in halves or thirds. And they hope it will get them through. For people with little money and no prescription drug coverage, this is an all-too-common reality. With Medicare Part D (Prescription Drug Coverage), it’s possible to have proper coverage for necessary prescriptions so they cost much less on an out-of-pocket basis. If you need medications when you’re younger, and see that you’ll need them as you age, this can be a good choice for you. Even if you’re not currently taking any medication, the odds of needing some will increase as you age. Getting Medicare Part D can help protect you.

Why Isn’t This Coverage Automatic?

When people qualify for Medicare, they only receive the standard part that covers doctors and hospitals. There are other options for further levels of coverage, including Part D, but this  coverage must be paid for. This coverage can be quite valuable if you take medication, or may medication in the future, it can be an investment toward protecting their health and their finances. While many prescriptions are affordable, some are still extremely expensive. Part of the reason that Part D is not automatically included is the already-high cost of healthcare. Additionally, the price of some medications, especially those for serious and chronic conditions, can be excessive. If all of this were paid for without any help from the patients themselves, it could become a problem for an already-burdened healthcare system. Charging for Medicare supplements like Part D helps the Medicare system continue.

What Does Medicare Part D Cover?

Medicare Part D is the prescription drug coverage supplement to the Medicare program. It covers needed medications for people who are on Medicare and who choose to pay for the additional coverage. Both traditional Medicare and Medicare Advantage (Part C) have options for you to also enroll in Part D. Some medications are covered without the need for Part D, but these are generally medications you’re given while in the hospital or as part of your discharge from a medical facility. Some drugs that require a doctor to administer them, such as infusion drugs, may be covered without the need for Part D. For most other types of medications, Part D is required and will cover at least a percentage of their cost. Generally, Part D will cover all types of prescription drugs. There may be some exceptions, so it’s very important to work with your doctor to ensure that anything prescribed to you is covered. In some cases, you may also need to switch medications.

How Much Does This Coverage Cost?

The cost of Medicare Part D will depend on several factors, including the cost of your prescriptions. Whether you get low-income help,  your medications are on the list of covered drugs, or you use an in-network pharmacy will also affect how much you will need to pay for Medicare Part D. If you feel that your costs are too high, there are options you can consider to reduce the amount you’re paying for the coverage and medications you need. You may also qualify for help with the actual price of the medications you take, or your copay. Not everyone who has Medicare and Part D coverage realizes this help is available, so it’s very important that you explore all your options and consider those choices carefully. Saving money and keeping good coverage should be the ultimate goal.

Avoiding the “Doughnut Hole”

The doughnut hole, or coverage gap, is a serious concern for people with Medicare Part D coverage. You hit this gap when you’ve paid  a certain amount for your medications and have reached an initial coverage limit. At that point, the Part D plan has paid as much as they have agreed to cover for your medications during a one-year time frame. Of course, you still need your medications, regardless of how much they actually cost. Once you reach your initial coverage limit, you’ll be asked to pay a bit more for your medications going forward. Fortunately, paying more means you’ll reach the catastrophic coverage phase faster. Once you reach that phase, you’ll have a small co-payment for the rest of the year, and won’t have to pay nearly as much for your medications. Depending on the cost of your needed prescriptions, you may reach the doughnut hole and the catastrophic coverage limit very quickly, or not at all.

Reducing Doughnut Hole Costs

There are also some other things you can do to try to avoid the doughnut hole so you don’t suddenly have to pay more for your medications. One way is to ask your doctor for generic or less expensive medication options. I Another way to pay less and avoid the doughnut hole is to use an in-network pharmacy and to be sure you’re using your Medicare Part D plan card every time you visit. That helps you pay less for your prescriptions every time you purchase them. Not everyone can avoid the gap, but your efforts can ease the financial burden. Apply for the Extra Help subsidy if your income is low. This will protect you from the doughnut hole and can prevent you from needing to do without your medications because of a sudden price increase. Even if you’re not sure if you qualify, there’s no harm in applying. You want to get all the help you can with your medical bills.

How Do You Get Medicare Part D?

You get Medicare Part D by signing up specifically for that program. Once you have Medicare or Medicare Advantage, or you’ve been notified that you are about to become eligible for Medicare, you can enroll in any supplemental programs that go with the standard Medicare benefits. There are specific enrollment periods you must follow, or you may find that you have to pay a penalty or wait longer for your coverage to begin. Instead of taking the risk of paying too much or being without coverage, be proactive in asking about when you need to sign up for supplemental coverage. Medicare has agents who can help you navigate the system so you don’t miss out on the coverage you really need. When you sign up for Medicare initially, you can also sign up for Part D. You’ll be able to enroll at a later time if you choose not to at first, but it won’t be as easy. Be sure to ask plenty of questions, so you know how the signup process will work at a later date.

Is This Permanent Coverage?

As long as you keep paying your premiums for Part D, your coverage will remain in place. If you stop paying premiums, or if you disenroll, you’ll no longer have Part D coverage. However, you must actively make a change for your coverage to end. It’s won’t be canceled without your knowledge unless there are serious and significant changes to the Medicare program overall. There are no current plans for any of these changes. Once you’ve enrolled in Medicare Part D and have started paying your premiums, you’ll have coverage that you don’t need to worry about. The medications you currently take, along with the ones you may need to take in the future, will be covered under your plan. It’s important that you find an in-network pharmacy close to you to benefit the most from your Part D coverage. You may need to switch pharmacies in order to be in-network, but the savings is generally well worth making the change.

Can You Cancel Medicare Part D Coverage?

If you signed up by mistake, or if you aren’t using Part D coverage, you can disenroll. You may, however, need to wait until an open enrollment period to make these changes. During that time, you should carefully evaluate any Medicare supplement programs you have purchased so you can decide whether or not you want to keep them. You’ll be able to re-enroll in the future if your situation changes. But keep in mind that you may have to wait for an open enrollment period again.

What If You Have Other Insurance?

If you have other insurance that offers prescription drug benefits, keeping that insurance is generally a good idea. This is especially true if the other insurance comes from the military, veteran’s benefits, or the federal government. There are many other types of insurance as well, including employer-sponsored plans, Medicaid, food stamps, and long-term care. Medicare Part D can affect, and be affected by, these insurance and benefit options. It’s best to ask about how you’ll be affected before you enroll in Part D, just to make sure it won’t create problems with any of the other needed benefits you’re receiving. This will reduce your risk of losing out on something you really need, and increase your chances of getting the maximum level of benefits you’re eligible for. When it comes to people on very fixed incomes, those with disabilities, and the elderly, that benefit level can be extremely important and should be carefully considered.

What’s the Bottom Line With Part D Coverage?

The bottom line is that Medicare Part D coverage can be extremely helpful for people who need help paying for expensive medications. Even with the “doughnut hole” in coverage, people can benefit from having protection from the high costs of some prescription drugs. That said, Part D may not be for everyone. It may not be cost-effective for someone who is not taking any medications at the time of Medicare enrollment. Just make sure you understand how and when you can enroll at a later date. That can help you avoid ending up without any coverage for a long period of time if you suddenly need medication. Many medications have an affordable generic option that’s affordable. If you’re not sure about Medicare Part D coverage, ask questions. The time to decide on whether you want the coverage isn’t when you’re stressed out and overwhelmed by the cost of medications you now have to take. It’s better to make a more relaxed and informed decision whenever possible. Know your options for Part D and consider them carefully, even if it’s not your plan of choice right now. That way. you’ll know what steps to take later if you decide that you need Part D and want to add it to the Medicare coverage you already have.
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This coverage can be quite valuable if you take medications, and for anyone who needs them in the future, it can be an investment toward protecting both their health and their finances.
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