Michael M Insurance Blog

Part D Prescription Drug Coverage

Mar 1, 2021 | 0 comments

Medicare does not cover Medications unless they are administered in a Doctors office or facility, in which case they will be covered under Medicare Part B. In order to get your Meds you will need to obtain coverage from a private company. They have monthly premiums, the national average is somewhere around $30.00. If your income is above a certain level you could pay more and if you don’t get one when you are first eligible you will get a penalty.


Medications are classified in Tier Levels. Examples are-
Preferred Generic
Preferred Brand
Non Preferred Brand
As you can imagine, the Copay will increase as you move from Preferred Generic to Specialty and the costs will vary between companies so it is very important to compare using your particular list of Medications.


Most Plans have a Deductible and as a rule the Deductible only applies to the higher Tier Drugs and generally not to the Generics. If you are on one of the Brands or a Specialty you will pay the Plan Deductible before the plan begins to Pay.


Simply, a Copay is a fixed amount and Coinsurance is a percentage of the cost.
Coverage Gap– “The Donut Hole”
This occurs when the beneficiary(You) and the insurance company spend up to a predetermined level. At that point, your cost share will increase, you are in the Gap or Donut Hole. When you reach another level of spending your cost share will dramatically decrease. When this happens is determined by how expensive your Medications are and people that are on Generics never get there.

The 4 Stages of Coverage

Deductible– The amount you will have to pay before your plan begins to pay. Generally this does not apply to Generics.
Initial Coverage– Deductible complete, the plan is covering your Meds and your cost share is copays and/or coinsurance if applicable.
The Gap– You and the Insurance Company have reached a predetermined level of spend and your costs have gone up.
Catastrophic Stage– You and the Company have reached the next predetermined level of spend and your costs have come way down.
There are programs available to Seniors that help with the costs of expensive Medications.
Extra Help- Is a Federal Program designed to help lower the cost of medications and help pay plan premiums.
State Help– Some States have their own programs such as EPIC which is a New York State plan. Check with your State for availability.
All programs are income based and if low enough some may qualify for their State Medicaid plan.

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