What Is Part D Medicare Coverage?

Prescription drugs are notoriously expensive, especially for the elderly and disabled who have high health care costs as is. Part D, Medicare's prescription drug benefit, was created to help out the elderly and disabled with their drug costs. It's a complicated system, but if you understand it, you can make it affordable and get the drugs you need.

What It Is

• Part D is how folks on Medicare get their prescription drugs. It is offered only through private companies. Enrollment in Part D is optional, even if you take other parts of Medicare. If you have drug coverage through another means such as retiree insurance that is considered "creditable" or as good as Part D, then you don't need to take it. If you decide you just don't want drug coverage, you also do not have to take it, but if you decide you do want Part D and you went uncovered, you will have to pay a penalty on your premiums.

History

• Medicare Part D is a relatively new benefit for Medicare recipients. It was created as a part of the Medicare Modernization Act of 2003, signed into law under President George W. Bush. Before 2003, Medicare recipients had no prescription drug coverage.

  Since its roll-out, many have criticized Medicare Part D because it is a very complicated and to some, confusing, benefit. Studies have pointed out that seniors don't understand what they are signing up for when they take a Part D plan.

Exclusions

• Drugs you receive from a hospital visit are not included under Part D, but rather, Part A, Medicare's hospital coverage. There are some drugs that are excluded from coverage under Medicare law. These drugs include those used to treat anorexia, weight loss, or weight gain; fertility; erectile dysfunction. Vitamins and over-the-counter drugs are also excluded, as well as anti-anxiety drugs such as barbiturates and benzodiazepines.

  Drugs used off the Food and Drug Administration label not listed in one of three Medicare-approved compendia are excluded from coverage. If you feel as though your Part D plan isn't covering a drug that they should, there is an appeals process in place.

Costs

• Part D's costs vary according to the private plan you select. Most Part D plans charge a monthly premium and you must meet a deductible before coverage will kick in. You will also be charged copayments. You will need to contact the Part D plan directly to find out these costs and charges. You can also check out the Planfinder on Medicare.gov.

  After your total drug costs reach a certain amount (varies by year), your Part D plan will stop paying for your drugs completely until your total out-of-pocket costs reach another amount. This is called a coverage gap, or the doughnut hole, and recent health care reform has plans to phase this out completely by 2020.

Public Programs

• If you have trouble paying for your Part D costs, you may qualify for a State Pharmaceutical Assistance Program or a federal program called Extra Help. Both of these programs help pay for the costs of Part D, including the premium, deductible, and some give coverage during the doughnut hole. Some even cover excluded drugs. Contact your State Health Insurance Assistance Program to see if you qualify.