Medicare Part D

Medicare Part D

Medicare Part D, also referred to as Medicare prescription drug benefit, is an optional program to help Medicare beneficiaries pay for self-administered prescription drugs through prescription drug insurance premiums. Coverage is provided through private insurance companies that have contracts with the Federal Government and is not provided directly by the government.

Medicare Part D is simply insurance for your medication needs. You pay your monthly premium to the Part D insurance carrier and use the insurance carrier’s network of pharmacies to fulfill your prescription medications. You pay a copay or percentage of the drug’s cost, instead of paying full price, and the insurance company will pay the rest.

Here's an example of a Medicare drug plan's tiers:
(your plan's tiers may be different)

 

To lower costs, many plans offering prescription drug coverage place drugs into different "tiers" on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.

  • Tier 1 - Lowest Copayment: most generic prescription drugs
  • Tier 2 - Medium Copayment: preferred, brand-name prescription drugs
  • Tier 3 - Higher Copayment: non-preferred, brand-name prescription drugs
  • Specialty Tier - Highest Copayment: very high cost prescription drugs

In some cases, if your drug is in a higher tier and your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) thinks you need that drug instead of a similar drug in a lower tier, you or your prescriber can ask your plan for an exception to get a lower coinsurance or copayment for the drug in the higher tier. Plans can change their formularies at any time. Your plan may notify you of any formulary changes that affect drugs you’re taking.

Medicare drug coverage includes drugs, like buprenorphine, to treat opioid use disorders. It also covers drugs, like methadone, when prescribed for pain. However, Medicare Part A covers methadone when used to treat an opioid use disorder as a hospital inpatient, and Medicare Part B now covers methadone when you get it through an opioid treatment program. Contact the plan for its current formulary, or visit the plan’s website.