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September 16, 2012
Texas Medicare Part D has certain limits on drug coverage that you should consider before choosing a plan. Medicare Part D drug coverage only applies to certain drugs and does not cover over-the-counter drugs such as aspirin. Your Medicare Part D plan does not include drug coverage for barbiturates, benzodiazepines and weight loss or weight gain medications. However government regulations do require that Medicare Part D drug coverage include the following six categories: antidepressant, antipsychotic, anticonvulsant, antiretroviral, immunosuppressant and anticancer drugs. Although Medicare Part D coverage is required in these categories each plan offers different drug coverage. Some Medicare plans offer drug coverage for generic drugs while others concentrate on brand name drugs.
The drug coverage offered by a Medicare Part D plan is known as the plan formulary. The formulary must include Medicare drug coverage for the most commonly prescribed drugs. This does not guarantee Medicare drug coverage for your specific prescription; your Medicare Part D plan coverage may only offer drug coverage for the drug's generic version. If coverage for a drug is eliminated from your Medicare Part D plan your provider will notify you 60 days in advance. You may have to switch to a comparable drug. Most plans use a tiered approach to determine the copay for each drug. Most generic drugs are on Tier 1 and have the lowest copay amount; Tier 2 has a medium copayment and offers drug coverage for common brand name drugs. Tier 3 and the Specialty Tier have the highest copay and offer Medicare drug coverage for unusual and high cost drugs. If your medications are in the higher tiers you may want drug coverage with a higher premium and lower copayments. Visit PlanPrescriber.com to compare Medicare Part D plan rates and drug coverage in your area.
Medicare Part D plans also have rules that affect drug coverage. Prior authorization from your doctor may be required for Medicare drug coverage in some cases. Your doctor will contact your provider and explain the medical reason drug coverage is needed before Medicare will approve the prescription. There are also quantity limits when it comes to Medicare drug coverage. If an above average amount of a drug is needed you may need prior approval for additional drug coverage. Step Therapy is a common part of Medicare drug coverage as well. Step Therapy provides Medicare drug coverage for cheaper generic drugs before more expensive drugs are prescribed. Your doctor will have to show that it is medically necessary for you to take a more expensive drug before Medicare drug coverage is allowed.
Another important thing to consider when selecting a Medicare Part D plan for drug coverage is your choice of pharmacy. You should make sure your Medicare Part D drug coverage includes pharmacies that are conveniently located. Medicare drug coverage may also include preferred pharmacies that offer low cost prescriptions. Some Medicare drug coverage may even include mail order programs that offer up to a 90 day supply of prescription drugs sent directly to your home.
Medicare Part D drug coverage is not accepted by most hospitals. This means you will only receive drug coverage for drugs covered by your Medicare Part B plan. It is important to bring any prescriptions with you whenever possible. Although there is a claim process that may allow for reimbursement, your provider may deny the claim or elect to only pay a portion of the cost.
Medicare has neither approved nor endorsed this information.