2104 SW 152nd St, Suite 2, Burien, WA 98166

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(206) 258-4670

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Part D

WHAT DOES IT COST?

  • Stand Alone Part D Prescription Drug Plan monthly premiums range from $14.50 – $100+. Your premium may be higher based on your income similar to the Medicare Part B premium. To see the Part D income-based premium chart click here.

  • Some Part D plans are included in the monthly premium of a Part C Medicare Advantage Prescription Drug (MAPD) plan.

  • Deductible – some plans charge the annual Medicare Part D deductible that you must meet before the insurance company shares in the cost of your Rx’s.

  • Cost sharing = Co-payments and co-insurance that you must pay for your prescriptions.

 

HOW ARE PRESCRIPTIONS COVERED?

Prescription drugs are classified and listed in a formulary:

  • Tier 1 = Preferred Generic Drugs

  • Tier 2 = Non-Preferred Generic and Preferred Brand Drugs

  • Tier 3 = Non-Preferred Brand Drugs

  • Tier 4 = Specialty Tier Drugs

Plans may have different coverage/tiers for drugs.

 

PART D BENEFIT STANDARDS

  • Deductible = $415 in 2019

  • Initial coverage phase (you + insurance company) cost share add the cost of your prescriptions to $3,820.

  • Coverage Gap phase (you) pay 25% for most brand name prescriptions and 37% for generics up to $5,100.

  • Catastrophic phase (you) pay the greater of $3.40 for generics, $8.50 for all other or 5% co-insurance, (company) the balance.

 

Once you enter the coverage gap, you may receive a 75% manufacturer discount on certain covered brand-name drugs and a 63% discount on generic drugs. Although you’ll only pay 25% of the price for that brand-name drug, the entire price will count as your TROOP (True-Out-Of-Pocket) spending towards the $5,100 that you must reach in out of pocket expenses during the coverage gap phase.

 

 

EXAMPLE

 

Mary is on a MAPD (Medicare Advantage with Prescription Drug coverage) plan that has waived the deductible for Part D. She is in her Initial Coverage period. When she goes into the pharmacy to fill her prescription, her co-pay is $40, but the retail price is $240. Mary will pay the $40 and her insurance company will pay the other $200. Mary and her insurance company just cost-shared the cost of her prescription. This keeps going on until both she and the insurance company combined have spent $3,820. Then she enters the Coverage Gap. Here she is responsible for the full price of her prescription unless her prescription qualifies for the 75% discount. She goes to her pharmacy to fill the same prescription as before. The price of the prescription is $240. Once the 75% discount is applied, the cost of the prescription is now $60.

Mary will pay $60 for the prescription, but the entire $240 will be counted as out-of-pocket spending and will help Mary reach the $5,100 so she can move to the Catastrophic phase of her Part D insurance benefit.

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