Part D Prescription Drug Coverage for 2013

Medicare began it’s Part D program January 1, 2006, in which it started to cover some of the costs medications that are taken home (that are prescriptions). The benefits of the program are offered/purchased through companies that have been approved by Medicare, specifically Medicare Advantage (that are managed care) and Part D plans. The reform act of 2010 (Obamacare) began a 10-year expansion of the Part D program that will completely close the donut hole. Many Medicare recipients have high annual prescription drug costs that the program doesn’t currently cover.

What Does it Cost?

Plans vary in cost, they begin at $0 and go up to about $90 per month for the most comprehensive plans, the average plans costs $30-$50 in monthly premiums. In every town/area there will be different plans on the market.

What Does It Cover?

Each plan has a formulary (which is a list) of medication that it will cover. A plan will only pay (a specific portion) for a drug on the list and it has to be purchased through a pharmacy that is within its network.

What will be your Plans Share?

There are four different payment stages for basic coverage and they are:

  • Deductible. You’re responsible for the first $320, there are certain plans that waive the deductible but they cost more.
  • Partial coverage. Once the first $320 is covered, you will be responsible for 25 percent of the costs while your plan pays the other 75 percent (the donut hole begins at $2,930). Your share will taken as a co-pay for each item that is purchased. Depending on your plan, the co-pay may be lower for generic drugs or higher for brand-name.
  • Coverage gap. As soon as your annual expenses reach $2,930 (and before you spend $4,700 in out-of-pocket expenses) you will be responsible for 100 percent of your prescription drug expenses (higher premium plans will cover a portion). As of 2012, brand-names have to sold at a discount of 50 percent and generics have to be sold for 14 percent less.
  • Catastrophic coverage. Once your costs reach $4,700 your Part D plan will cover 95 percent of your expenses leaving you with 5 percent.

Part D: a Corporate Giveaway

The entire prescription drug program is managed by insurance companies, which means, premiums pretty much go towards paying for their profits and their incredibly inefficient overhead.

In addition, there is a provision within the Part D law that doesn’t allow Medicare to negotiate for lower drug costs only the private companies are allowed to… private companies are not going to bother with negotiations any time soon to save Medicare recipients money.

The Veterans Administration  has been negotiating with pharmaceutical companies for years and there drug prices are half as much compared to any Part D plan. Medicare has the ability to utilize this same exact buying power but the law prevents Medicare from negotiating with pharmaceutical companies for lower pricing.

Medications from Canada

Prescriptions drugs cost anywhere from 50 to 80 percent less in Canada, this is for the exact same drugs that are available/manufactured in the USA. The Public Health System in Canada limits/regulates how prescriptions can be priced (pharmaceutical companies still manage to make lots of money).

The FDA has made it illegal to import medications (at a commercial level) from Canada in order to protect drug companies (obviously, at the expense of consumers). Since October 2006, Customs has stopped taking in mail-order prescriptions that are being imported.

Certain Drugs/Prescriptions Excluded by Law

Medicare prohibits certain categories of drugs from being covered in a Part D plan. It doesn’t matter if it’s prescribed by your doctor and some of these categories Medicaid will actually cover, they are:

  • sedatives and sleeping pills of a sort
  • specific types of tranquilizers
  •  weight loss or weight gain related drugs
  • over-the-counter medications

Part D Formularies for 2013

Every plan has a list of drugs that it will cover and it must include 2 drugs from every “therapeutic class” (Medicare requires it). A plan can offer more then two options and it can charge more for having more within its formulary.

Your plan will cover any share of the cost on any medication if it’s not on the plans formulary. Anything you spend on non-formulary prescriptions will not be put towards your deductible.

Tiered Co-payments

Insurance companies are allowed to charge different co-pays for different medications even for prescriptions that are a part of the same ‘class’. Generally, they require lower co-payments on generic drugs and higher for brand-name or different co-payments on brands of the same class/category.

Overcoming a Formulary Restriction

Every Part D plan has some type of system (at least two) in place which allows its recipients to challenge/question its listing or how it covers a specific medication.

  1. It has to have a system for requesting an “exception” to its formulary. For this type of exception you’d need your doctor to prove that it’s a medical necessity.
  2. Regularly, plans changes their rules and how they price medications. Every plan has to allow people to appeal its decisions through a process that is completely run by the insurance company. If the ‘internal’ review doesn’t workout then you may go after an independent review in court.

Drug Substitution

Part D programs are allowed to contact your pharmacy and have them substitute the prescription drug that you request with a therapeutic equivalent one (even if it’s not exactly what your doctor prescribed). This means, your plan can have the pharmacy dispense a different drug to you as long as it is therapeutically equivalent. “Equivalence” doesn’t mean it has to have the exact same effect on you. What your doctor prescribes may be more effective for you (and have less side effects) but your plan can over rule what your physician recommends. You can fight your plans substitution policy through an appeal.

Step Therapy 

A plan can enforce a treatment structure in which its recipients have got to give a certain drug a shot, it’s most likely a less expensive alternative, before they will cover another of the same class. If this happens, your physician will have to get involved and let your insurer know that you’ve tried the alternatives.

Supply Limits

For each prescription that you have filled and co-payment will be necessary. To keep costs down you can have your doctor prescribe a few months worth of a medicine at a time. Part D plans tend to block this tactic by placing a supply limit on how many doses can be fulfilled at a time.

Deciding on Participation of Part D for 2013

Medicare has created an actual monetary penalty for those that delay enrollment into a plan unless you are enrolled with an employer or union sponsored health plan which is considered ‘creditable coverage’. For every month that you delay enrollment into a plan you will be penalized with a 1 percent increase in premium, up to a maximum of 24 percent.

If at all possible, see if there are any Part D plans that are free in your area so you don’t have to incur the penalty when you are ready to sign up for a plan.

Let us know if you’ve got any questions on Part D enrollment, exceptions, and appeals or on how switching to a different plan works.


Obamacare vs. Medicare Part C

apparently, Advantage plans have not been hurt…

Has Obamacare, fronted by the Obama administration, swung any punches in the ring, or are they both playing on the same team? According to the administration estimates as of September 19, not only is Obamacare not hurting any of the private Medicare Advantage Plans but doing the opposite. They claim they are aiding in the development of Medicare Part C.

28% – that’s the rate of growth as projected by Medicare and Medicaid Centers for the Medicare Part C rolls. Premiums will have dropped 10% and the benefits will flow consistently. The director of the CMS Center for Medicare declined the authenticity of these projections during a conference call. The ACA (Affordable Care Act) froze all benchmark payments to Most Medicare Advantage Plans last year and started reducing them this year at a rate parallel to the service fees. He then stated then in two years the plans would have to use a minimum of 85% of their premiums back into medical care.

Quote from source Politico: But Blum said the sustained interest from insurers that CMS was seeing for 2013 suggested that the program would remain strong. “Plans don’t usually make strong commitments in one year just to pull out the next,” he said. Republicans, however, say it’s too early to say Medicare Advantage is safe.”

The Senate Finance Committee Republicans did not respond as politely. They blared a release revealing the harsh, cold reality of it all – only 4% of the savings the ACA should wring from Medicare Part C is now in motion, and the Government Accountability Office highly doubts the legitimacy of a proposed eight billion dollar program intended to rise payments to these plans to get appraised quality marks from the CMS, which is supposed to start this year.

In defense, a Republican senator of Utah tells the press that the program was made to protect the plans from downsizing until the election’s conclusion.

According to the CMS, the average premium is projected to rise by $1.47 to $32.59 in 2013, which is less than 2010’s $36.14. On a lighter note, the CMS also expects the availability of Advantage plans to benefits to rise by 7% in that same year. For the first time ever, Medicare beneficiaries (starting in this fall’s open enrollment season) will receive a notification informing them if they are currently enrolled in a plan so bad that the CMS won’t automatically renew them. The lists of companies which qualify under the conditions of the notification are expected to be released to the public in the near future.

Read more:

Programs for Seniors that Don’t Cost Anything

Everybody will eventually retire some day, and keeping the cost of living in proper balance is going to be a struggle most of us will have to deal with. Health insurance coverage or long term care insurance can help, but often this is not enough to get by,

Many are unaware of how easy it is to receive additional help for little effort through public resources. Here is a compilation of resources one can tap into in order to gain access to the assistance which aids hundreds for financial security: Non-profit website who will ask for the basic personal information required in return for a detailed report of programs, contacts and access information. Health, disability, income, worth, veteran status, education level, and personal information are all key components to answer in order to get the most out of this website. Upon completion of your personal form, you will receive a generated response of a list and details of government programs and services for your benefit.

Medicare. Besides Part A and Part B insurance, low income receivers who rely on social security can be subsidized down to $10/month payment in premiums.

Social Security. Also known as Supplemental Security Income (SSI), this is a service one may be eligible for if the previous social security revenue was from a poorly paying job as the only source of income.

Department of Veteran Affairs. This handy website,, offers a variety of compensational packages for veterans who are experiencing service related disabilities.

Administration on Aging. The AOA over at oversees a surplus of programs throughout the nation for the elderly, which include: legal assistance, health insurance counseling, elder abuse protection and long term care.

HIPAA An act in 1996 issued as the Health Insurance Portability and Accountability act secures everybody with the privatization of all medical records, in the event a waiver sign granting permission for record sharing has not been signed. Visit for more information regarding this subject.

Government Your US senator at, your congressional representative at and the US Department of Justice at can provide a plethora of programs and services for the elderly who qualify.

Area Agency on Aging Federally mandated and available in any city, this agency consists of a panel of professionals who are knowledgeable in every aspect of elderly programs and available services, all within your area. is the database in which this panel resides.

Between all of these resources, one is sure to find a service or program to ensure financial stability and receive the health treatment and care services they deserve. Also, see this guide on how to get a phone for free.

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