Part 1: How Medicare Part D Works

Does Medicare subsidize Part D drug coverage for everyone, or just for people with low incomes?

The federal government subsidizes coverage for everyone enrolled in any Part D drug plan. But it gives much bigger subsidies to those with low incomes (who qualify for Extra Help) and for people of any income level whose drug costs are high enough to take them to the catastrophic level of coverage in a year. The government also gives subsidies to employers, unions and others that provide retirees and active employees age 65 and over with drug coverage that is at least of equal value to Medicare drug coverage.

Are there any cost breaks for married couples?

No. Each spouse pays separate premiums, deductibles and copays for prescriptions and will reach each level of coverage according to his or her own drug costs over each calendar year. Ideally, each spouse should choose a Part D plan according to his or her own drug needs, rather than automatically signing up with the same plan.

How do I pay the premium?

You can choose to have it deducted from your monthly Social Security check or pay it directly to your Medicare drug plan by check or electronic bank transfer. (You may want to pick one of the latter options, especially if you’re likely to switch to another Part D plan at the end of the year, because Social Security doesn’t always deduct the correct amount in a timely manner.)

What does a “year” of coverage mean?

It means a calendar year, Jan. 1 through Dec. 31, regardless of when you enroll. The cycle of coverage (deductible, initial coverage period, coverage gap, catastrophic coverage) starts over each Jan. 1.

What if I join Medicare and enroll in a Part D plan partway through the year?

The cycle of coverage follows the same order (deductible, initial coverage period, coverage gap, catastrophic coverage). There is no reduction in the deductible (if your plan has one) if you start partway through the year.

Will I be able to get all the drugs I take now?

Maybe, but not necessarily. Each plan has a list of preferred drugs it covers, known as a formulary.

A plan must cover at least two drugs in each class of drugs used to treat the same medical condition. It must also cover nearly all drugs used in six classes: antidepressants, antipsychotics, anticonvulsants, antiretrovirals (for HIV/AIDS), immunosuppressants (for transplants) and anticancer drugs.

A few drugs are excluded from Medicare coverage by law. Among them are medications for fertility, erectile dysfunction, weight problems and cosmetic uses, over-the-counter drugs and certain anti-anxiety treatments (barbiturates and benzodiazepines such as Valium and Xanax). However, under a recent change in the law, barbiturates and benzodiazepines will be covered under Part D starting 2013.

Plans are allowed to change some of the drugs they cover during the year. If this affects a drug you are using, your plan must inform you of the change at least 60 days in advance, unless it has been withdrawn from the market for safety reasons.

You have the right to ask your plan to cover a drug not on its formulary by requesting an “exception” to its policy if your doctor can show that a non-formulary drug is necessary for your health.

Before granting an exception, a plan may require you to try a drug that is already on its formulary and similar to the non-formulary one you take now, to see if it is equally effective in treating your medical condition.