Ways to get the most out of a Medicare Part D prescription drug plan
For many older adults, taking medication is part of their daily routine. A Medicare Part D prescription drug plan may help provide the medication benefits members may need.1
Here are some key things to know about maximizing the benefits of a Medicare Part D prescription drug plan.
Know the coverage options
There are 2 ways to get a Part D prescription drug plan. People who have Original Medicare can purchase a stand-alone Part D plan. These plans have a separate monthly premium. Or people can purchase a Medicare Advantage plan that includes prescription drug coverage.1
Check the plan’s drug list (formulary)
Each Medicare Part D prescription drug plan provides a drug list for each of the plans it offers. This drug list is also called a formulary. Not only does the formulary list all the prescription medications the plan covers, but it also gives details about the costs. 2
Drug lists are typically organized into 3 or more coverage tiers that determine how much the drug costs. Generally, the lower the tier, the less the prescription medication will cost.2
In addition to drug tiers, the drug list will describe any restrictions that may apply to each drug. These are the most common ones:3
- Prior authorization. The plan may require more information from a provider before covering the drug.
- Quantity limits. The plan may only cover a certain amount of the drug per fill.
- Step therapy. A person may need to try a clinically equivalent, lower-cost drug before the plan will approve a clinically similar, higher-cost one.
On a health plan’s website, the cost of covered drugs is typically a few clicks away. For example, when logging into the UnitedHealthcare® member site, the drug cost estimator tool can quickly find pricing for a covered drug at nearby retail pharmacies. It can also find pricing at a home delivery pharmacy. (Note that not all medications can be delivered right to a home.)
Learn more about the Part D coverage stages
Medicare Part D has 4 different stages of coverage. The amount a member may pay for medications can vary in each stage. Here are the basics:
- Stage 1, annual prescription deductible stage: In this stage, for plans with a prescription drug deductible, a person pays out of pocket for covered drugs until they meet the deductible amount, after which the plan begins covering the cost of covered drugs. However, some plans don’t have drug deductibles or do not apply deductibles to lower-tier medications.4
- Stage 2, initial coverage stage: This stage starts after the deductible is met. If there’s no deductible, this stage starts right away. In the initial coverage stage, the plan pays part of the cost of covered drugs and the member pays the applicable copay (flat fee) or coinsurance (percentage of the cost).
The actual amount members pay generally depends on the applicable drug tier. Members stay in the initial coverage stage until they reach the initial coverage limit set by Medicare for that year.
- Stage 3, coverage gap stage: This stage begins after the initial coverage limit is reached. When a member reaches this stage, they pay a percentage of the cost of covered drugs. It’s important to note that not everyone will reach this stage.5
- Stage 4, catastrophic coverage stage: After a member’s total out-of-pocket drug costs reach the yearly limit set by Medicare, they leave the coverage gap stage and enter the catastrophic coverage stage. In the catastrophic coverage stage, a member only pays a small coinsurance percentage for Part D-covered drugs for the rest of the year.6
To see estimated costs of specific drugs in each coverage stage, members can use UnitedHealthcare’s drug cost estimator tool. Current members with Part D coverage can also see which coverage stage they’re currently in.
Work with a health plan to discuss your options
Every person’s medication needs are different — and can vary from year to year — so it’s worth taking a little time to chat with plan experts about your health and budget needs to help ensure your plan meets those needs before you sign up.
If you have any questions about your Part D coverage, you can also take advantage of your health plan’s online or digital resources. And at the beginning of each new plan year, it may also help to work with a plan to discuss your options and ensure you’re able to maximize the benefits.