Prescription drug coverage under the Medicare program is a complex system of rules that will probably baffle many of your prospects when you first try and explain it to them. This brief overview will help you to remember the most important aspects that you need to communicate to them.
PDP’s and MA
There are various Medicare plans that don’t offer drug coverage, such as certain PFFS plans and Medical Savings Account plans. For these plans beneficiaries could opt for a Prescription Drug Plan (PDP) if they would like coverage for prescription drugs. There are also Medicare Advantage plans that provide drug coverage. On these plans the beneficiary gets Parts A, B and D coverage through the same plan.
Eligibility for Medicare Prescription Drug Plans
The basic eligibility requirement is that a beneficiary must have either Part A or Parts A and B under Original Medicare, or have A and B if they have a Medicare Advantage Plan. Medicare PDP’s also operate according to specific service areas, so of course the prospect needs to live within the region covered by their chosen plan’s service area.
Premiums and Penalties
Coverage and costs vary for different PDP’s. Many Prescription Drug Plans have an annual deductible that applies to their beneficiaries’ coverage. This deductible amount has to be met before the plan starts paying anything. When one of your prospects decides to join a PDP, they also need to remember that they will have to pay the PDP monthly premiums in addition to their Part B premiums. This additional Part D premium varies from one plan to the next, but it will be higher if a beneficiary has to pay a late joining penalty.
Copayments and Coverage Gaps
Most PDP’s include copayments or coinsurance. It is important to mention this to your prospects, since they will have to pay a certain portion for covered drugs while the drug plan covers its share. Most PDP’s also have a “coverage gap”. This means that after a certain amount has been spent on drugs covered under the plan, the beneficiary will have to pay all costs – subject to an annual limit. This annual limit includes the deductible, copayments and expenses paid during the coverage gap. After the limit has been reached, your prospect becomes eligible for what is known as “catastrophic coverage” – they will then only have to pay a small copayment for any specific covered drug until the end of the year.
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