Licensed Medicare Part D agents represent virtually every insurer in the United States. No one knows the rules and regulations of the Medicare industry better than the local insurance agent.
Medicare Drug Coverage: Know the Limitations
Which Drugs Are Not Covered By Medicare Part D?
The main criticism of Medicare Part D plans is that there are varying lists between plans; that is to say, you can expect to find a different list of excluded drugs by different plan providers.
There is, however, a so-called “base line” list of drugs that Medicare Part D excludes. These include, of course, drugs disapproved for use by the Food and Drug Administration, drugs not available in the United States and drugs that are available under Part A and Part B of Medicare.
There are also certain classes of drugs that are excluded in Part D, including:
- Fertility drugs
- Drugs for weight gain, weight loss, or for treating anorexia
- Drugs for treating erectile dysfunction
- Cosmetic drugs
- Cough and cold suppressants
- Vitamins and minerals except prenatal vitamins
Although they are excluded in a basic Medicare D plan, plan providers can otherwise include them as a supplementary benefit if they fit a Part D drug definition. The costs of such drugs, however, cannot be passed on to Medicare.
The Difference in Part D Plans:
Not all Part D plans are created alike. In fact, Part D Medicare plans are not even required to pay for all drugs that are covered under Part D. Different plan providers have their own set of formularies, or list of Part D drugs that they are willing to make a payment.
It pays to check out the formularies of the plan providers in your area. Choosing two to three plans would typically be enough, but if you have time to waste, you can actually go through all the plans available in your area (some areas in the United States have 100 plans offered by 50 different providers).
Keep in mind that with each year, Part D plan providers tend to change their formularies or the list of drugs covered under their plans. This is one reason why Part D plans are patronized only by a fraction of the people who are set to benefit from it. The minimum amounts or the Standard Benefit Plan changes with each year too.
The Donut Hole, and How it Affects You
Medicare Part D has a coverage gap, often referred to as the ‘donut hole’, where drug coverage ceases once you reach a threshold in your standard cover plan; this threshold (as of 2013) stands at $2,700.00, with benefits starting again if you spend $6,154.00 or more.
The $3,454.00 ‘hole’ is one of the most contentious issues in the whole Medicare initiative. Whilst plans do exist that will cover you for all your prescription drug expenses, they are far more costly and beyond the affordability of many Medicare customers.
One of our agents can advise you as to your likelihood of needing extra cover for the coverage gap, and how much you will expect to pay, should you reach the coverage threshold.
Among Medicare Beneficiaries:
- 26% spent over the $2,700.00 threshold
- Of these, the average beneficiary spent approximately a third of the year in the Donut Hole
- 15% of these (four percent of total beneficiaries) received cover over $6,154.00
Changes to Medicare Part D in 2013:
This is certainly the case of the Medicare D 2013, where there are increases in the deductible amount, coverage limit, maximum amount of out-of-pocket expenses, and co-payment. Part D is an optional supplemental coverage to your main Medicare plan, but if you opt for this plan, you would typically pay from $35 to $37 per month (as of 2013 Part D).
Medicare Part D plans come in different forms: HMO plans, PPO plans, Program of All-Inclusive Care for the Elderly (PACE) plans, and Medicare Private-Fee-for-Service plans. Enrolment for the 2013 Part D doesn’t start until November 15, 2013 (it ends December 31, 2013).
You can enjoy the benefits of your Part D Medicare plan right away at the beginning of 2013. If you decide on a Medicare Advantage Plan during the Part D enrollment period but would like to switch to a PDP plan at the start of 2013, you can always make the switch from January 1 to March 31, 2013, during a special enrolment period.