Medicare Part D


The coverage of prescription drugs under Medicare Part D is assured and coordinated by private insurance companies authorized by Medicare.


All beneficiaries eligible to benefit from Medicare Part A and Part B and who permanently live in the service area of a Medicare Part D Prescription Medicine Plan may enroll in a Medicare Part D.


Enrolling in Medicare Part D may be optional; however, you may pay penalties if you cannot enroll in Medicare Part D as soon as you qualify and pay later.

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Part D Prescription Drug Plan Key Points

Part D of Medicare is merely insurance for your medication requirements. The beneficiaries can sign up for an independent Part D Medicare Plan, which goes hand in hand with the Original Medicare benefits.


Individual Medicare Advantage Plans feature an integrated Part D Drug Plan. Monthly premiums are payable to the insurer for the Part D plan. In exchange, you benefit from the insurance company’s pharmacies network for the purchase of prescription medications.


Rather than paying full price, you will pay a percentage or co-pay of your medication costs. Your insurance company is responsible for the rest.

During 2020, Part D members face significant increases in the cost of out-of-pocket medicines before qualifying for catastrophic coverage.


This happens because The Affordable Care Act limited the increase in the cost of out-of-pocket drugs for Part D members by moderating growth rates for the catastrophic thresholds from 2014 to 2019.


Current thresholds will increase by $1,250 in 2020, from $5,100 to $6,350 for out-of-pocket spending.


In 2020, as in previous years, Part D members will also have to pay higher out-of-pocket costs, both in the deduction and initial coverage phases.


Standard deductibles increased from $415 in 2019 to $435 in 2020. Meanwhile, the initial coverage limit increased from $3,820 in 2019 to $4,020 in 2020.


For any costs incurred during the coverage gap phase, beneficiaries pay 25% for both branded and generic medicines. The remaining 75% for generic medications are paid for by their Part D insurance plan.


As a result, this means that Part D’s coverage gap, which will become effective in 2020, will be eliminated.


Medicare contributes 80% of the total cost of drugs exceeding the catastrophic threshold. The plans pay 15%, and members pay either 5% of the overall cost of drugs or $3,60/$8,95 on generic or branded drugs, respectively.


Enrolling in Medicare Part D plans is optional, except for seniors who qualify for both Medicare and Medicaid plus some other low-income beneficiaries automatically enrolled on a prescription drug plan when they do not select the plan themselves.


If you do not have drug insurance from another source, which is at least equal to the standard insurance from Part D, also known as “creditable coverage.”


They may impose a penalty of 1% of the national average premium for every month of late enrolment.

Confused? We can help!

Call us today and we'll help you find the plan that fits your life and your needs.

“I was all awash trying to figure out my medicine expenses. I spent a few minutes talking to Las Vegas Medicare Pros, who helped me understand it all.”

J Rogan

North Las Vegas, NV

Annual Deductible

In 2019, the permitted part D deductible for drugs was $415. Schemes may deduct the entire Part D deductible, partial deductible, or cancel the deductible altogether. 

You will pay the network discount price for all your medications until your plan reaches a level that will satisfy your deductible. Then you enter the initial coverage.


Initial Coverage

At this stage of Part D of your medication coverage, you will pay a co-pay for your medication based on the drug formulary.

Any drug plans would split your drugs into levels.  Each level will have a co-payment you will pay.

Your insurance company also tracks your and your insurance company’s expenses to where you jointly spend $3820 in 2019.


The Coverage Gap

Once you have reached the initial coverage limit for that year, you enter the coverage gap. During the Gap, you will typically have significant discounts on generic medications.

You will then pay for only 25% of brand name medications and 37% for generic medicines. The spending Gap will continue until your total out-of-pocket medication spending reached $5,100 in 2019.


Catastrophic Coverage

When you reach the end of your coverage gap, the plan will be in place to cover 95% of your drug formulary costs for the rest of the year.

This characteristic in Medicare Part D drug plans helps you cap the potential expenses you incur should you have any expensive medications.

Medicare keeps track of your TrOOP (True Out-of-Pocket Costs) for every year.

With them doing this, it can prevent you from paying some costs twice. For instance, you may already satisfy the deductible in one plan. You later move halfway through the year into a different Part D Medicare scheme because you have left the state.

You see that you have already paid the deductible for that year. Your coverage gap and your catastrophic coverage costs will work in the same manner.

Medicare Part D drug plans will also change year after year.  Your plan benefits, formulary, pharmacy network, provider network, and your premium, co-payments, and co-insurance have the potential to change on January 1 of each year. However, you may switch your plans over the annual election period that runs from October 15 to December 7 of the year.

Medicare enables drug plan carriers to enforce some rules for reasons of safety and also to contain costs. The most usual rules of usage you can find are:


Quantity Limits

Restrictions are in place for the amount of medication you can purchase at once or at each refill.

Should your doctor prescribe any more than the quantity limit, then your insurance company will require him or her to complete an exception form to account for why more is necessary.


Prior Authorization

A requirement that either you or your doctor has to get approval from the plan before letting a pharmacy dispense your medication. Your insurance company may request proof of a prescription before permitting it. You find this affects medicines that are expensive or very strong.


Your doctor has to show why this medication is necessary for you and why alternative drugs can be harmful or ineffective.


Step Therapy

The plan demands you try cheaper alternative medications that treat your condition before they will contemplate coverage of the prescribed medication.

Should the alternative medication work, then both you and your insurance company can save money. If the alternative medication is not working, your doctor will help you file your drug exception request for coverage for your provider’s initially prescribed medication.

They will explain the reason you require more expensive medication when affordable alternatives are available. This will often need him to prove you have tried less expensive options that were not effective.

These restrictions can affect your overall Medicare prescription costs. Remember to check your Medicare plan formulary to determine if conditions apply to any of the important medications you take.

Many people believe that switching from one drug plan to another is going to help. However, sometimes, nearly all Part D carriers have limitations.

Such limitations are common for pain medications, narcotics, and opiates.

Should you take a significant amount of pain medication, be aware you will regularly deal with additional paperwork, regardless of which medication plan you choose.

It doesn’t matter what plan you are on; you will encounter these things.

Also, some medications are outside Part D coverage. Should you take medicine, not in the formulary, like a compound medication, we urge you to contact us:

  • To help you get approval for your medication, we have procedures in place to assist you in filing the exception.
  • We have also helped many of our beneficiaries decrease their out-of-pocket costs by merely assisting them in filing Tier Exceptions for their medications.

Not every exception passes approval, so please be aware that you may be liable for any medication not covered by your plan or Medicare Part D overall.

Medicare Part D drug plans are one of the more confusing subjects.

We’ve had clients join plans before Las Vegas Medicare Pros Nevada and drug specialists sign them up before checking if the formulary includes their medications. Some of them have lost some of their medicines, which have step therapy rules in place.

Please contact us, and we’ll help you select a provider with the lowest estimated annual expenses.