Because original Medicare coverage (Medicare Part A and B) offers coverage for only the drugs administered in a hospital or by a primary care physician.
The prescription drugs your doctor prescribes for you to purchase is entirely different from that which will be administered to you during treatment in a hospital or by a primary care physician because you will be required to purchase the prescribed medications outside of a professional setting. In this situation, your original Medicare coverage will not cover the expenses; therefore, you will need a prescription drug insurance policy to cover the expenses you may incur for self-administered prescription medications.
Medicare Part D is an optional add-on Medicare insurance that is not included in original Medicare, in which you can choose to purchase to benefit from the prescription drug coverage they will offer you for self-administered prescription drugs. Medicare Part D Plans are sometimes called prescription drug coverage that primarily protects you from the expenses you may incur from any prescription drugs you get outside of the hospital.
You can also be a beneficiary of prescription drugs coverage if you have Medicare Part C Plans (Medicare Advantage Plans).
Medicare Part D Plan, sometimes called prescription drug coverage, also follows the principle of exchanging cash for coverage performed by other non-Medicare health insurance plans. In this principle, the policyholder will be required to pay a specific premium charge monthly and annually, on a regular basis. In exchange, your Medicare insurance provider will cover a percentage of your drug expenses each month. Once you sign up for a Medicare Part D Plan, you will be required to go through four specific stages. These stages include:
– Annual deductible
– Initial coverage
– Coverage gap
– Catastrophic coverage
The annual deductible is the amount of money the insured will be required to pay towards your prescription for a duration of a year before the policyholder’s insurance coverage becomes active. It begins to cover the expenses you may incur from any prescription drugs. According to studies and research, Medicare Part D providers do not charge their policyholders above $415 in an annual deductible.
Initial coverage is also referred to as copayments, which is the specific amount of money an insured individual is expected to pay when receiving treatment. This payment stage will commence after the insured individual annual deductible. In this payment stage, the Medicare Part D Plans provider will also begin to cover the agreed percentage of the insured individual until the Medicare Part D Plans provider and the insured individual both spend $3,820 in total ($3,820 is the initial coverage limit).
The policyholder will reach this stage of payment after they and their insurance provider have spent up to the initial coverage limit, which is $3,820. The coverage gap is the third stage of payment where the insured person will be required to pay almost the entire expenses they incur from prescription drugs until they reach the coverage gap limit of $5,100.
Once the insured person has spent up to the coverage gap limit of $5,100, they will enter the last stage of payment—that is, Catastrophic coverage. In Catastrophic coverage, the insured person will be paying a specific amount of money towards prescription drugs with either generic or brand name when receiving treatment (copayment). However, unlike initial coverage, the insured will be paying a lower copayment during their Catastrophic coverage ultimate payment stage.
Medicare is made up of several parts that vary in their insurance coverage; they are, however, legal in every state in the United States of America and everyone with a Medicare plan. These plans can be purchased together either as an add-on or stand-alone insurance policy, but it is illegal for anyone to have a Medigap insurance policy together with Medicare Advantage Plans (Medicare Part C Plans).
The government controls only the original Medicare coverage—that is, Medicare Part A and Medicare Part B insurance. On the contrary, Medicare Part D Plans insurance coverage (also called Prescription drugs coverage) are provided by private health insurance providers that are Medicare-approved.
There are a few sets of Medicare rules designed for the safety of the insured and cost regulation. These rules make Medicare Part D Plans providers add strict restrictions towards their drug usage. Some of these rules include the following:
– Prior authorization
– Step therapy
– Quarterly limits
There are few circumstances in which the insured or their primary care physician will be given prior authorization to provide confirmation that the drugs they prescribed to the insured person are requisite for the treatment of their medical condition. This is primarily because Medicare Part D Plans providers are determined to cover the prescription drugs expenses that are medically requisite, especially if the drugs prescribed are costly brand name drugs.
Step therapy is more of a testing stage, in which the policyholder is given generic drugs in order to test the effectiveness of the active ingredients to their medical conditions before the use of brand name drugs, especially if the generic drugs do not treat the insured medical conditions. However, in order to all the direct use of brand name drugs rather than the prior testing of the effectiveness of generic drugs, the insured primary care physician or specialist will have to file an except request with their insurance provider if they strongly believe that the use of generic drugs would be dangerous or ineffective for the treatment of their policyholder’s medical condition.
Quarterly limits involve the maximum amount of medication a policyholder should use for a particular period for refills. Every individual’s prescription drugs have their specific quarterly limit; hence, if the insured is prescribed drugs that are more than their quarterly limit, their doctor will be required to explain in writing why the insured needs that much of a medication.
There are several Medicare Part D Plans providers with convincing coverage promises, amongst which Wellcare, Humana, EasyCare and Aetna are part of the best insurance providers. However, knowing your medical needs before undergoing comparison shopping is the best way to find a prescription drug coverage that will suit your requirements.