INSURANCE – JULIA RUSCITTI– THE BASIC PLAN – So what are the basics of Part D?  The bill (originally signed by President Bush) is 411 pages long, and takes a CIA decoding team to understand.  Do I dare try to summarize it on one page?

Since 2006, Medicare Part D has offered beneficiaries assistance with their prescription drugs. The coverage is handled by private insurance companies, and the monthly premiums vary; depending on how much coverage the plan provides.

You can get the Part D benefit as a “stand alone” policy that only covers drugs, (appropriate for those beneficiaries with supplemental of Medigap plans) or in a Medicare Advantage plan that integrates the drug benefit within the plan, itself.

Under Medicare Part D, private insurance companies will enter into contracts with the Department of Health and Human Services to provide insurance for prescription drugs.  The coverage requirements (such as use of formulary drugs, tier assignments, etc) under the plans will vary by state; to reflect differences in provider costs and patient demographics.

In 2006 (the first year of the RX program), the average monthly premium was approximately $35.  In 2012, there has been a slight increase to approximately $40 per month.  Please note, however, the premium is based on the benefits of the plan, and what is covered (or not covered) by the plan selected.

WHAT DOES PART D COVER? Each plan has its own list of covered drugs (called a formulary).  Many Medicare drug plans place drugs into different “tiers” on their formularies.  Drugs in each tier are assigned a different co-pay; based upon their retail value – or what you would pay if you did not have a drug plan in place. 

DRUG PLAN COVERAGE RULES- Medicare drug plans (stand alone and/or integrated) may have the following coverage rules: 

Prior Authorization (PA)- You and/or your health care professional must contact the drug plan before you can fill certain prescriptions.  The plan will need to know that the particular drug is medically necessary, and a lower cost generic or alternative drug is not suitable.

Quantity Limits (QL) Limits on how many months can be filled at one time.  For instance, most drugs can be filled for 90 day intervals.  However, some drugs can only be filled for 30 days at a time.  This is determined by the individual plan.  

Step Therapy (ST)- The plan is asking you to try one or more similar (usually lower in cost) drugs to see if they can provide a cost savings and still have comparable medical benefits.

Please note:  If you or your healthcare professional does not agree with any of the above referenced rules, you can always apply for an “exception”. 

On my next blog we will discuss the “Enrollment Penalty”

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