So, you’re about to retire and you finally qualify for Medicare! As you begin to examine the many different Medicare plans, you might feel confused. Why would any one plan be better or more necessary than another? Moreover, why don’t most plans cover drugs and medications, but Medicare Part D seems to cover a lot of that?
Most Plans Are About Providers, Office Visits, Treatment Plans, Etc.
The purpose of Medicare is to provide medical coverage to seniors and retirees who no longer have coverage as a result of not being employed. Without medical coverage, a lot of older adults are left without the services they need to live longer, healthier lives. Yet, most plans refrain from covering medications, drugs, and procedures, leaving these things up to Medicare Plan D.
Medicare Plan D, as in Plan for Drugs
When Medicare was created, there was an understanding that not everyone would require medications. In fact, there are a lot of older adults that don’t need any medications at all. Paying for prescription medications when you don’t need them is not something a lot of people are willing to do, especially on a tight monthly budget.
Ergo, Plan D was developed as an “a la carte” option to add to any of the other Medicare plans. The idea was to provide a separate drug plan for older adults that do need medications and/or may need medications in the near future. The coverage also looks at some medicinal treatments that even the best Medicare plans do not cover.
The Formulary Tiers of Plan D
Since the government likes to simplify medical coverage as much as possible to make it more affordable, there are formulary tiers for drugs. The lowest co-pay and most likely generic drugs are in Tier 1. Higher co-pays and some name-brand drugs that don’t have a generic are in Tier 2.
Tier 3 contains several non-preferred (i.e., drugs the government would rather not cover due to cost) name-brand medications and the highest co-pays. The fourth and final tier features specialty medications with a really high cost and very high co-pays. You’re not likely to get these drugs approved for treatment unless your doctor can convince Medicare that no drug on a lower tier will be effective for what ails you. In each tier and for every known medication or type of medication for a specific ailment, the government offers two drugs. For example, if you have high blood pressure, you need an antihypertensive medication. The Plan lists two commonly prescribed antihypertensives it’s willing to cover for you. If you currently don’t take either of those two medications, your doctor has to request a waiver to allow you to continue taking the medication you have been taking all along.
What Happens When Your Medications Aren’t Covered
As previously mentioned, not all medications are covered under Plan D because the government considers certain medications to be effective and less costly. If you retire and qualify for Medicare and your medications that you have been taking for several years aren’t covered under the usual tiers of Plan D, you need a waiver.
The waiver is a plea to Medicare telling them that the medications you take are necessary and that:
- You can’t take anything else because it would have a bad interaction with other medications
- The covered medications under the Plan do not work for you
- You have shown an allergic or negative reaction to the covered drugs
- You have a history of trying the covered meds, and they didn’t work as expected
- There is no other medication to treat your medical issue and not taking said medication could cause loss of life
There may be other acceptable and accepted reasons why a waiver would persuade Medicare to cover your medications. Your doctor can review the possible reasons that Medicare may accept. You should be aware however that Medicare may still deny your waiver and want you to take medication that is covered. It is a remote possibility, but a possibility, nonetheless.
Recent Changes to Coverage for Insulin
For a long time, insulin wasn’t a covered drug because it wasn’t considered a drug. Even when it was finally covered by Medicare Plan D, it cost an enormous amount of money making it impossible for diabetics to afford every month. Recent government changes to how insulin is covered under Medicare has lowered the cost of insulin significantly, and there are even programs to help seniors pay for their insulin.
If you need insulin, you have Plan D, and you qualify for the insulin program, you will never be required to pay more than $35 every month for your insulin. That’s really good news for diabetics and seniors everywhere that rely on this hormone to sustain quality and longevity of life.
Enrolling in Plan D
To enroll in Medicare Plan D, you will first need to select a primary Medicare plan. You cannot enroll in Plan D by itself. You have to select Plan A or B. (Plan C is supplemental and meant to cover co-pays and costs of A and B that patients can’t afford without supplemental insurance.)
You will also need to wait for open enrollment. If you did not enroll in Plan D at the time you chose A or B, you will have to wait until the next enrollment period. This typically occurs once a year, or whenever the one-year mark on your current plan has just passed. If you have had your plan A or B for one year, you are allowed to continue with your plan or change it, which acts as another “open enrollment” period. Then you can add Plan D to your coverage.