Part D Benefits
While dually eligible beneficiaries residing in nursing homes have a zero cost responsibility, the basic benefit is available to all other Medicare beneficiaries for a monthly premium which averages roughly $25 nationwide.
| The basic Part D benefit for 2008 is as follows: | |
|---|---|
| Deductible | Beneficiary pays the first $275 of covered drug costs |
| Initial Benefit Period | Beneficiary pays 25% of the next $2,235 ($558.75) |
| Donut Hole | When covered drug expenses reach a total of $2,510 (combined expense of $275 + $2,235 by BOTH the beneficiary and the PD), the beneficiary pays 100% of the next $3,216.25 |
| Out of Pocket so far: | (the amount paid by the beneficiary) $4,050 |
| Catastrophic Coverage | After the beneficiary has paid $4,050 in total out of pocket drug costs ($275 + $558.75 + $3,216.25) the beneficiary pays a minimum co-pay of $2.25 for generic / preferred drugs and $5.60 for all other drugs. |
Some Medicare Part D plans will offer better than basic benefits, but none will offer less. Some of the variations in benefits may include:
- Reduced or zero deductible
- Reduced or variable co-payments
- Coverage of some drugs during the gap “donut hole” period
In addition, each plan uses a Drug Formulary which determines whether or not the drug prescribed by the doctor will be covered or not. Even if the drug is covered by the plan, they may impose certain restrictions such as:
- Limits on the quantity of drug that can be dispensed (Quantity Limits)
- Requirements that certain drugs be tried before others will be covered (Step Therapy)
- Doctor providing certain information and explanations before the drug will be covered (Prior Authorization)
Even with these limitations, the beneficiary may contest coverage limitations. This process will take into account circumstances as explained to the PDP that support the use of the drug in question.
It is important that each beneficiary make a decision based upon his/her medications in relationship to the plan’s formulary, formulary restrictions, cost of premiums and additional benefits that may be available. The CMS Plan Finder can be a valuable tool to assist beneficiaries in selecting the Part D plan that best meets their needs.