Health Care

Ask these questions before picking a Medicare Part D plan

Choosing a Plan D, the Medicare plan for prescription drugs, can be complicated.
Choosing a Plan D, the Medicare plan for prescription drugs, can be complicated. Kaiser Health News

Enrollment for Medicare Part D prescription drug coverage starts on Oct. 15 and runs through Dec. 7

Prescription Drug Plans provide stand-alone prescription drug coverage to Medicare beneficiaries, and work alongside Part A (hospital) and Part B (medical) coverage.

Medicare Part D was the result of legislation passed in 2003, and signed into law by President George W. Bush in 2006. You can only go to Medicare-approved private insurance companies.

Florida, which had about 35 percent of the state’s Medicare population enrolled in stand-alone prescription drug plans in 2015, according to eHealthInsurance Services, has 22 stand-alone Part D plans. Premiums range from about $18 to $175 per month.

To be enrolled on Part D, you must enroll through one of the prescription drug companies that offers the Medicare Part D plan or directly through Medicare at If you are enrolled in Medicare, you are eligible for a Medicare Part D prescription drug plan, but there are a few things you should know before selecting a Part D plan.

Pharmacy technician Krista Volk fills prescription orders. Darin Oswald Miami Herald file photo

Are my prescriptions on the plan’s formulary?

Each Medicare drug plan has its own list of covered drugs, called a formulary. Drugs not on the formulary are generally not covered by private plans.

Does the plan impose any coverage restrictions?

Step therapy is a coverage restriction placed on drug coverage by private health plans. In this case, before your plan will cover some more expensive drugs, you must first try other less expensive drugs to see if they will be effective.

Questions about drug costs, a site powered by the Medicare Rights Center, advises asking these questions about costs:

How much will I pay at the pharmacy (copayments or coinsurance) for each drug?

How much will I pay for monthly premiums and the annual deductible?

How much will I have to pay for brand-name drugs?

How much for generic drugs?

What will I pay for my drugs during the coverage gap?

If a drug I take has a very high coinsurance, is there a drug I can take that will cost less? (Ask your doctor.)

Questions related to pharmacies

Am I eligible for Extra Help or a State Pharmaceutical Assistance Program (SPAP)?

Can I fill my prescriptions at the pharmacies I use regularly?

Can I fill my prescriptions when I travel?

What will my coverage options and costs be if I visit out-of-network pharmacies?

Can I get prescriptions by mail order?

Improvements in Part D

AARP recently published a quick-guide of how Medicare will improve next year. Of the notable highlights, there will be no more therapy caps, meaning Medicare beneficiaries won’t have to pay the full cost of outpatient physical, speech or occupational therapy.

Better and more user-friendly information will be available, like updated handbooks with checklists and charts to make it easier to decide on coverage; improved online features will show out-of-pocket costs between original Medicare and Medicare Advantage plans.

The availability of telehealth programs, which let patients consult with doctors or nurses via telephone or the internet, will be expanded.

“Test drives” of plans will let people try an Advantage plan for up to three months.

After that time, they can either choose to keep it or they can switch to another Medicare Advantage plan or choose to enroll in original Medicare.

An early close of the donut hole

You enter the donut hole when your total drug costs, including what you and your plan have paid for your drugs, reach a certain limit. For most plans in 2018, this amount is $3,750.

Currently, after a beneficiary’s out-of-pocket spending reaches $5,000 for covered drugs, he or she enters catastrophic coverage leaving the donut hole, the amount between the $3,750 and the $5,000, when benefits are not as good.

The donut hole was scheduled to close in 2020, under the Affordable Care Act (ACA), but the spending bill that Congress passed in March will close the donut hole for brand-name drugs in 2019. For generic drugs, the gap will close in 2020.

In 2019, Part D enrollees will be responsible for paying 25 percent on brand name drugs in the donut hole (once they reach an initial coverage limit of $3,820 in 2019) rather than the current 30 percent. They will still pay 37 percent for generics in 2019, according to, one of the largest independent online resources for Medicare Part D and Medicare Advantage plan information.

Beneficiaries will also enter the catastrophic coverage phase earlier in 2019, since more drug costs will count toward meeting the coverage threshold.

Potential Part D drug cost changes

President Trump is in talks with Congress to limit beneficiaries’ out-of-pocket costs for prescription drugs under Part D, which would help Medicare recipients with high drug costs. A recent New York Times article detailed the president’s proposal to switch some expensive drugs from one part of Medicare to another part — moving them from Part B, which covers medical services and supplies, to Part D.

Under Part D, the government is able to negotiate discounts with drug makers. This arrangement is off the table for the drugs covered by Part B.

“People may see a lot higher out-of-pocket costs if a drug moves from Part B to Part D,” warns David M. Certner, the legislative policy director of AARP.

Medicare beneficiaries typically pay a larger share of the costs for Part D drugs. A recent Associated Press report found that there were fewer price increases for brand-name prescription drugs this year from January through July than in comparable prior-year periods, but companies still hiked prices far more often than they cut them.

In June and July, right after Trump’s price cut prediction, there were 395 price increases and 24 decreases, the report found.

How to sign up

Any beneficiary who is eligible for original Medicare, Part A and/or Part B, and permanently resides in the service area of a Medicare Prescription Drug Plan, can sign up for Medicare Part D.

You can get Medicare Part D coverage through a stand-alone Medicare Prescription Drug Plan if you’re enrolled in original Medicare.

If you’re enrolled in a Medicare Advantage plan, you can get drug coverage through a Medicare Advantage Prescription Drug Plan. Different insurers offer different types of plans, so your monthly plan premium and out-of-pocket expenses will vary from plan to plan.

If you need help

SHINE (Serving Health Insurance Needs of Elders) is a free program offered by the Florida Department of Elder Affairs and the local Area Agency on Aging. Specially trained volunteers can assist with Medicare, Medicaid, and health insurance questions by providing one-on-one counseling. Call 1-800-96-ELDER to talk with a volunteer.

You can always call a Medicare representative at 1-800-633-4227 and ask for unbiased assistance finding a Medicare plan that most economically covers your health and prescription needs.