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Senior Life: Tips for Healthy Living - Medicare

Pharmacy

Have you ever wondered what is covered under the different parts of Medicare?  Your Lewis Drug Pharmacists knows that Medicare can be confusing and that choosing a plan that is best for you may be a challenge.  The following will help explain the different parts of Medicare along with a few tips to keep in mind when evaluating your current prescription drug plan or selecting a new plan this Fall. 

  • Medicare Part A: Hospital Insurance (Inpatient care)
    • Also covers:
      • Skilled nursing facility care (That is not custodial/long-term)
      • Hospice care
      • Home health care
  • Medicare Part B: Medical Insurance
  • Medicare Part C: Medicare Advantage Plans
  • Medicare Part D: Prescription Drug Insurance

Medicare Prescription Drug Coverage 

  • Prescription drug coverage is a benefit that is optional, but available to anyone with Medicare
    • You may receive a late enrollment penalty if you do not enroll when you are first eligible
  • Plans vary in what medications are covered and their cost
    • Medicare.gov is a helpful tool to search for Medicare Part D or Advantage Plans
  • Prescription drug coverage can be obtained through a Prescription Drug Plan (PDP, Part D) or a Medicare Advantage Plan (Part C). 
  • Part C: Similar to a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) that offers prescription drug coverage. Medicare Part A, B, and D are all included. (Must have Part A and B to join) (Also referred to as MA-PDs)
  • Part D: Adds drug coverage to original Medicare (Parts A and B)
    • There is an annual deductible which is the amount you are responsible for each year before your drug plan will pay its share for your medications. The amount varies by plan and some do not have one. In 2021, no Medicare drug plan could have a deductible over $445. The amount for 2022 has not yet been released. 
    • Copays or coinsurance are the amount you will pay for covered medications after you meet the deductible. Coinsurance may change throughout the year based on changes in your total medication expenses. This also changes based on the tier your medications are assigned to. 
      • Once you and your drug plan spend a combined total of $4,130 on medications you will enter the coverage gap (“donut hole”). In the coverage gap, you will not pay more than 25% of the cost of your medications until you reach the $6,550 out-of-pocket maximum. This amount includes your deductible. 
      • Patients who get extra assistance with paying for their Part D plan will not have a coverage gap. 
        • The amount may change each year, the amount for 2022 has not been released. 
        • After the coverage gap is met, you then enter catastrophic coverage for the rest of the year. This means you will pay a small coinsurance percentage or copay for medications that are covered. 

When can I sign up for Medicare prescription drug coverage? 

  • When you turn 65
  • If you are newly eligible for Medicare due to a disability (<65 years old) 
  • If you don’t have Medicare Part A and enrolled in Part B during the Part B General Enrollment Period (Eligible for a Medicare PDP from April 1st to June 30th)
  • If you have Medicare Part A and enrolled in Part B during the Part B General Enrollment Period (Eligible for a Medicare Advantage Plan from April 1st to June 30th)

When can I make changes to my current prescription drug coverage?

Open enrollment period runs from October 15th through December 7th each year

Changes that can be made during the annual open enrollment period include:

  • Change from Original  Medicare plan to an Advantage plan and vice versa
  • Change to a different Medicare Advantage Plan
  • Change from a Medicare Advantage Plan without drug coverage to one with it, and vice versa
  • Change Medicare drug plans
  • You also may enroll in Medicare Part D (prescription drug) if you didn’t when you were first eligible or you may cancel your prescription drug coverage

Medicare Advantage Plan Open Enrollment is from January 1 to March 31st

Changes that can be made during this enrollment period include:

  • Switch from one Medicare Advantage Plan (with or without drug coverage) to another
  • Drop the Medicare Advantage Plan and return to Original Medicare. (Can then join a PDP, if desired)

Changes that cannot be made: 

  • Change from Original Medicare to a Medicare Advantage Plan
  • Join a Medicare PDP if in Original Medicare
  • Switch from one PDP to another if in Original Medicare

Who can help me evaluate and sign up for a Medicare Part D plan? 

  • Pharmacists
  • Insurance agents
  • State organizations 
    • South Dakota has a program called Senior Health Information and Insurance Education (SHIINE) which is federally funded
      • Located in Eastern, Western, and Central South Dakota
      • Provides free, unbiased, and confidential information to Medicare recipients
      • Visit their website at http://shiine.net/home.html for more information

What immunizations are covered by Medicare? 

  • Medicare Part B covers the annual influenza immunization along with pneumonia and hepatitis B immunizations. 
  •  Medicare Part D covers the shingles immunization along with Tdap (Tetanus, diphtheria, and pertussis coverage). 

Medicare Part B is considered medical insurance. However, under some conditions, it covers some outpatient prescription medications and supplies. These are often medications you would receive at a clinic or hospital.  For these medications, patients pay 20% of the amount approved by Medicare and the deductible applies. In an outpatient setting, the co-pay is also 20%. If medications are not covered by Part B in a hospital outpatient setting, the patient will pay 100% unless they have Part D or other prescription drug coverage where the amount paid depends on the plan’s coverage. You can check your Part D medication formulary to see what medications are covered in the outpatient setting.

References: 

Medicare.gov-The Official U.S. Government Site for Medicare. https://www.medicare.gov/. August 5, 2021. 

Senior Health Information and Insurance Education. http://shiine.net/home.html.  August 5, 2021.

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