LINCOLN, Neb. – Medicare prescription coverage can be a complicated subject with 23 drugs plans to choose from, various plan rules that determine your out-of-pocket cost and potential restrictions that could interfere with your prescribed therapy. Understanding what these rules are and what you can do concerning potential restrictions is important to ensure your drug therapy stays on track. In addition to this you need to be aware of how a Medicare prescription drug plan works. The different rules can affect what you pay.

What is a Medicare prescription drug plan?

A Medicare Part D Prescription Drug Plan is a separate insurance plan those on Medicare purchase to help cover the costs of their medications. Part D covers both brand-name or generic drugs. Part D does not cover over the counter medications nor does it cover most prescription vitamins and mineral products. If you choose to get your Medicare coverage through an Advantage Plan you typically do not need to choose a Part D Plan. Most Medicare Advantage Plans offer the same drug coverage as a Part D plan.

What costs can you expect with prescription drug coverage?

Prescription drug plans charge a premium. This year the premiums range from $20 - $101. Other costs associated with your prescription drug coverage may include a deductible, up to $405 this year, and copays and/or coinsurance payments. The copays and coinsurance are the out-of-pocket you pay for covered drugs after you have met your deductible. There are different phases during the calendar year that determine your out-of-pocket. Depending on the phase you could see these copays and coinsurance amounts fluctuate during the year, resulting in your out-of-pocket costs ranging between 5% and 44%.

What can you do if you are having trouble covering your prescription costs?

There are a few options available for those people who may be experiencing difficulty covering their prescription costs. One option is known as Extra Help. Extra Help is a federal program that helps pay for some to most of the out-of-pocket cost of Medicare prescription drug coverage. Extra Help is also known as a Low-Income Subsidy or LIS.

In order to qualify for Extra Help you will need to meet income and asset requirements. A single individual must have monthly income less than $1,538 per month and assets limited to $14,100. A married couple living together must have income less than $2,078 per month and assets limited to $28,150. Note that the asset limitation does not include one vehicle or the home in which the individual resides.

Extra Help offers the following benefits:

n Assistance paying for some or all of your Part D premium

n Lowers the out-pf-pocket cost of your prescription drugs including your deductible and copays or coinsurance

n Eliminates any Part D late enrollment penalty you may have if you delayed enrollment

Are there any other options to help with Part D drug costs?

If you do not qualify for Extra Help there are other potential options to help with your prescription drug cost. One option is a Patient Assistance Program (PAP). A PAP may be able to provide free or low-cost drugs directly from the company that makes them.

Other options include speaking to your doctor about your current medications. Are you currently taking a name-brand drug that has a generic option? Generics drugs are often less expensive than brand-name drugs, so it is a good idea to find out if a generic could work just as effectively as the brand-name drug. Also, if you are experiencing temporary difficulty covering you medications you may be able to ask your doctor for samples.

If your drugs are not covered by your plan or if your drugs are covered but are assigned to a high cost-sharing tier, you can appeal to your plan for a formulary exception, asking the plan to cover the drug not on their drug list, or a tiering exception, asking the plan to assign your drug to a lower-cost sharing tier.

If you have questions about Extra Help, Patient Assistance Programs or other Medicare drug coverage questions you can contact Nebraska SHIIP at 1.800.234.7119. Nebraska SHIIP is a division of the Nebraska Department of Insurance and is the State of Nebraska’s source of unbiased Medicare education and counseling.