What questions should I ask of a Part D prescription drug plan?
Medicare Part D, the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone prescription drug plan (PDP), for those enrolled in Original Medicare, or a set of benefits included with your Medicare Advantage Plan.
You should make sure to find a Part D plan that meets your specific health care needs. Before you start looking at plans, gather a list of the prescriptions you take, including their dosages and usual costs, and the pharmacies you regularly use.
Here are some questions you should ask before choosing a Part D plan:
- Are my prescriptions on the plan’s formulary?
- The formulary is the list of prescription drugs for which a Part D plan will help pay.
- Does the plan impose any coverage restrictions, such as prior authorization, step therapy, or quantity limits?
- Prior authorization means that you must get approval from your Part D plan before the plan will pay for the drug.
- Step therapy means that your plan requires you to try a cheaper version of your drug before it will cover the more expensive one.
- Quantity limits restrict the quantity of a drug you can get per prescription fill, such as 30 pills of Drug X per month.
- If the plan does not cover a medication I take, does it cover one that will work for me? (Ask your doctor.)
- How much will I pay at the pharmacy (copayments or coinsurance) for each drug I need?
- How much will I pay for monthly premiums and the annual deductible?
- How much will I have to pay for brand-name drugs? How much for generic drugs?
- What will I pay for my drugs during the coverage gap?
- If a drug I take has a high coinsurance, is there a drug I can take that will cost less? (Ask your doctor.)
- Am I eligible for Extra Help or a State Pharmaceutical Assistance Program (SPAP)?
- What is the service area for the plan?
- Can I fill my prescriptions at the pharmacies I use regularly?
- Can I fill my prescriptions when I travel?
- What will my coverage options and costs be if I visit out-of-network pharmacies?
- Can I get prescriptions by mail order?
Coordination with other insurance
- Will Part D work with other coverage I have to lower my costs?
- Do I need to enroll in Part D if I have other creditable coverage?
- Do I need to enroll in Part D if I have job-based drug coverage?
There is no one best Part D plan for everyone. Instead, you should ask questions and make sure to find a Part D plan that meets your specific health care needs.