Insurance Information Part 3

Insurance Information Part 3 5November

Medicare Part D

It’s that time of the year again! The fall Medicare open enrollment period is October 15 through December 7. New patients who have turned 65 and anyone who is already enrolled in Medicare Part D should come to the Wickenburg Community Hospital Pharmacy to get a free consultation during this enrollment period.

So, what is Medicare Part D? The Medicare prescription Drug, Improvement, and Modernization Act of 2003 established prescription drug coverage under Medicare. Now Medicare has Part A, which covers hospital insurance, Part B, which covers doctor visits and medical supplies, and now Part D, which covers prescription drug insurance. There are two types of plans one can choose from. This first is known as the standalone Prescription Drug Plan (PDP) in which drug coverage is provided from private insurances. This type of insurance requires enrollment in either Part A or Part B. Then there is the Medicare Advantage Plan, which requires enrollment in both Part A and Part B. The Advantage Plan also has other benefits such as dental and eye care. Whichever plan you choose, it is important to have prescription drug insurance.

So, how does Part D work? First off, there is a standard prescription drug coverage that all participants will have. The enrollee will first pay a deductible (in 2018 it was $405 and in 2019 it will be $415). Once the deductible has been met, then the enrollee pays 25% of the cost of their medications, and the plan covers 75% up to an initial coverage limit (in 2018 the limit was $3,750 and in 2019 it will be $3,820). Once this limit has been reached, the enrollee goes into a stage known as the coverage gap, or “doughnut hole.” During this time, the enrollee must pay for the majority of their medications until they reach $5,000 in total out-of-pocket costs (in 2019 it will increase $5,100). After they have reached the threshold, then they go into another stage known as the catastrophic coverage. During this stage, Medicare subsidizes 80% of the costs, and enrollees pay either a specific co-payment ($3.85 for generic drugs and $8.35 for brand name drugs) or a 5% coinsurance.

In regard to how much actual money you spend will depend on what plan you decide to get. For example, some plans cover part of the initial coverage, as well as help, cover some costs during the coverage gap.

So, why should you come for a free consultation? Every year the Center of Medicare and Medicare Services changes the formula and updates the Part D coverage parameters of the deductible, initial coverage limit, and out-of-pocket amount. As shown earlier, participants in Part D will have to pay a little more out-of-pocket. Also, every year, insurance plans change their premium, co-pays, deductibles, and formularies. Therefore, the plan that you are on now, may not be the best plan for next year. Your insurance plan may increase or decrease the prices of drugs they cover, preferred pharmacies may change, and drug utilization management requirements may differ.

It is important to sign up for Medicare when you reach 65 because if you decide to not have any type of medical insurance and postpone joining Medicare later, there is a penalty tax for late enrollment that is permanently added to your premium. The penalty is based on 1% of the national base premium multiplied by the number of full months the patient went without coverage. For example, if the premium is $35.02 and you waited 30 months to enroll, you would have to pay $10.50 extra each month on your premium for the rest of your life.

There are certain kinds of drugs that Part D will cover and certain drugs that it will exclude. As long as the drug is included in the formulary drug plan and FDA approved, it can be covered. Vaccines and insulin are also covered. What Part D does not cover are drugs for anorexia, weight loss, weight gain, fertility, cosmetics such as hair growth, and erectile dysfunction. Prescription vitamins and medications to help relieve cough and cold symptoms are also excluded.

There are a variety of different ways you can sign up for Part D. You can fill out a paper application, visit the Medicare’s website at, call the company to sign up, or you can call 1-800-MEDICARE. In order to be eligible for Medicare, one has to be 65 or older, a U.S. citizen, and have never been incarcerated.

At the Wickenburg Community Hospital Pharmacy, we provide free consultations for patients who are enrolled in Part D as well as new patients who are enrolling in Medicare Part D during the enrollment period between October 15 through December 7. As pharmacists, we will be able to evaluate your medication lists and find the best drug plan specifically suited for your needs.

Wickenburg Community Hospital Pharmacy is now accepting consultation appointments.

Call the pharmacy at (928) 684-4380  to schedule a free Medicare Part D consultation with a pharmacist and see how much money you can save next year.

Primary Care

Community Hospital Clinics are located in Wickenburg, Wittmann, and Congress. We sincerely follow our mission to provide quality health and wellness services where the patient, family, and community come first.

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