Medicare Part D Coverage in Oregon

In need of Medicare Part D Coverage in Oregon?

Medicare beneficiaries are encourage to enroll on a Medicare Part D (PDP).  Medicare Part D drug plan is an optional Medicare insurance plan that covers prescription drugs and medications. It is important to sign up when you are first eligible or you may have to pay penalty. Part D drug plans in Oregon start at $6.30 per month or no premium if you choose to enroll on a Medicare Advantage plan that has a built drug plan. About 40% of people on Medicare in Oregon are enrolled on a Medicare Advantage Plan.

Cost of Medicare Part D in Oregon 

According to CMS, nationwide premiums the average cost for Medicare Part D is around $33/month. This includes standalone PDPs and Medicare Advantage Plans with drug coverage. The average cost for a standalone PDP in 2022 is $43 per month.

Costs of Medicare prescription coverage vary depending on:

• The drugs you use
  
• The plan you choose
  
• Whether you go to a pharmacy in your plan’s network
  
• Your plan’s formulary — if the drugs you use are on it
  
• Whether you get “ Extra Help “ — Extra Help also called as LIS (Low Income Subsidy) helps pay for the cost of Medicare Prescription Drug Plan. This assistance program is for Medicare beneficiaries who has limited income and resources. Know more about Extra Help

>>> Click to view Explainer Video.

How to choose a Medicare Part D (PDP) Plan

You may want to ask yourself these questions before choosing a prescription drug plan.

• How often do you take prescription drugs?
• What are the types of drugs that you take?
• Would you prefer to have a plan with a higher deductible or a higher premium?
• Do you need a stand alone drug plan or enroll on a Medicare Advantage Plan that has a built in drug plan?

You may also want to consider the amount of out- of-pocket copays and coinsurance that will take effect once you entered your Donut Hole. Also, it is important to check your plan every year to make sure your prescriptions are covered.

How to compare Medicare Part D Plans in Oregon

The best way to compare all the drug plans is to use Medicare.gov  or give us a call and we’re happy to help you. 

What drugs are covered by Medicare Part D?

Medicare Part D plans may cover drugs that are:

• Available only by prescription
• Used for a medically accepted condition
• Approved by the FDA
• Sold and used in the United States
• Not covered under Original Medicare, Part A or Part B

In addition, these plans are required to cover at least two types of drugs in each therapeutic class, alongside with vaccines and supplies and to cover almost all drugs in these categories: antidepressants, anticonvulsants, antipsychotics, immunosuppressants, cancer drugs, and HIV/AIDS drugs.

Take note:  There are drugs that are not covered under Medicare Part D.

Each Medicare prescription coverage policy decides which drugs not to cover on its formulary, the list below are some drugs that are not covered (not a complete list).

• Drugs for cosmetic purposes or hair growth
• Weight loss or weight gain drugs
• Fertility drugs
• Drugs for sexual or erectile dysfunction
• Over-the-counter drugs
• Any drugs that are covered under Medicare Part A or Part B.

What are drug tiers?

Most Medicare Part D plans place each drug category into tiers, the higher the tier the more expensive it is. In some cases, if you find a drug in a lower tier similar to the one in the higher tier, an exception may be applied. You can also ask your doctor or provider if there is a generic drug equivalent to the one that you are taking.  

Here is an example of how drug tier was divided:

• Tier 1 — Most generic drugs. This will cost you the least amount
• Tier 2 — Preferred brand-name drugs. This may cost you more than Tier 1 drugs. This tier is proven to be the most effective.
• Tier 3 — Non-preferred brand-name drugs. These drugs may cost you more than Tier 1 and Tier 2 drugs.
• Tier 4 — Specialty drugs. These drugs are the most expensive because they are unique, branded and not preferred.

Can I get help on paying prescriptions?

Yes. There are some programs that can help reduce drug costs.

• Extra Help(Low Income Subsidy)– helps pay for your prescriptions. The help comes from Social Security. You have to meet certain income and resources.  
• Patient Assistance Programs: Brand-name drug manufacturers have programs to provide discounts or no-cost medications to those who qualify. They normally ask you to provide proof of income and spending on the prescription to be able to get approved.
• Generics: Consult with your doctor about taking any generics as a good substitute for expensive brand-name drugs.
• “Best” Price: Using in network pharmacy within your drug plan will save you the most on co-pays. Mail order 90 day supply can also reduce your cost. Some plans don’t charge you a copay for generics or they charge 2 month’s copays instead of 3 months. Another strategy that may work is to ask your pharmacist for the “best” price for a certain prescription. Sometimes costs for drugs may be less if you do not use your insurance. Keep in mind that any drug you purchase outside of your insurance will not count toward satisfying your deductible, or getting you out of the donut hole.

Prescription Drug Plan Coverage Rules and Limits

Most plans may set coverage rules and limits for proper implementation and utilization especially when medically necessary.  Some of these are:

1. Prior authorization – Plans may require prior notice before accepting prescriptions to cover. For this matter, your doctor may need to provide reasons that these drugs are medically necessary.
2. Step therapy  – Doctors may require you to take a low cost drug with the same effectivity as the branded one before you can “step up” to a drug with a higher cost. Otherwise, if the generic drug won’t be an effect to you, they need to provide more information to set out the coverage rule of your plan
3. Quantity limits  – Plans may offer a time limit for your medications. For an instance, they may set 30 days of medication to your heart treatment. After the period set and the doctor thinks that you still need more time for treatment, he can extend the time frame by contacting your plan.

Part D penalty

There’s a late enrollment penalty depending on how long you went without Medicare Part D coverage or creditable prescription drug coverage. Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($32.50 in 2019) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.

Simply stated, Medicare Part D coverage is for covering prescription medications. But there is a little more complexity about Medicare Plan D that should be broken down.

4 Stages of Medicare Part D coverage:

Medicare Part D covers medication worth $3,820 per year. Most Medicare Part D plans have a deductible. For 2019, there’s a $415 deductible. If the Prescription Drug Plan has an annual deductible, you pay the full amount of your prescription drug purchases until the deductible is met.

• After you have reached the annual deductible, you will pay a share of the costs according to the terms and structures of your plan. Your share, which you typically pay to the pharmacy at the time of pickup, could be a flat amount (copayment) or a percentage of the total amount (coinsurance). Most generic prescriptions vary from $0-$12 per drug. Brand names are around $37- $47 per drug and specialty could be from 40-65% of the cost of the drug. Each prescription drug plan differs so it’s important to review the drugs you take and which drug plan covers them at a lowest cost.
• Once you’ve reach $3,820 for the year, you will reach the donut hole. Your copay for brand name will go as high as 25% of the costs and you’ll pay 37% of the costs for generic drugs.
• Once you have paid a certain annual maximum amount out of your own pocket for prescription drugs, you automatically get “catastrophic coverage”. In 2019, you and the Part D plan should have paid $5,100 for the year to be out of donut hole. This means for the rest of that particular year, you would only pay a small copayment or coinsurance. The cost of medications is substantially reduced. It’s around $3.30- $8.50 amount for prescription drugs.

What are the Changes of Medicare Part D Prescription Plans in 2022?

Coverage change every year. New proposed changes may affect the donut hole and some beneficiaries are yet to determine the effects of these changes. Let us address these changes one by one.

Initial Coverage Limit for 2022 Medicare Part D

The Initial Coverage Limit (ICL) will go up from $4,130 in 2021 to $4,430 in 2022. The initial deductible will increase by $35 to $480 in 2022. In the Donut Hole, you’ll pay 25% for brand-name drugs. The manufacturer will give you a 70% discount during this time, and your Medicare Part D plan will pick up the remaining 5%. The 25% you pay plus the 70% discount from the manufacturer will count toward your combined TrOOP (see below), which is when you exit the Donut Hole.

Standard Initial Deductible for Medicare Part D in 2022

A jump of $35 from 2021, deductible is now at $480 and goes towards your of out of pocket threshold. Deductible is the amount that you need to pay for your medications before your plan kicks in. It won’t affect when you enter the Donut Hole portion of your coverage, but it will once you left Donut Hole and entered Catastrophic Coverage.

Total Out of Pocket Threshold (TrOOP) for Medicare Part D in 2022

TROOP is the amount that you need to pay to exit the Donut Hole and enter Catastrophic Coverage. It was a difference of $500 from 2021, increasing it to $7050 for this year.

Donut Hole Brand Name Drug Discount

Enrollees will receive a 70% discount for branded medicines. 70% of which is provided by the brand manufacturer and the remaining 5% will be paid by your part D plan. So if you are taking a branded drug that costs $100, you just need to pay $25, making the discount and your payment count towards your Donut Hole.

Donut Hole Generic Drug Discount will Increase

The situation is different for generic drugs. You still pay 25% yourself, and your Medicare Part D plan covers the other 75%. However, only the 25% you pay yourself counts towards meeting your TrOOP. The Medicare Part D total out-of-pocket threshold will bump up to $7,050 in 2022. Catastrophic Coverage copays will cost between $0.25 to $0.65 more in 2022 compared to the previous year. You will now pay $9.85 for brandname drugs and $3.95 for generics (or 5% of retail costs, whichever is higher).

Change in Formulary

Be aware that your Medicare Part D coverage may change its formulary. You may want to review the Annual Notice of Change that the plan sends you every fall to make sure your drug plan will still cover your prescription medications in the coming year.

How does Medicare Part D work with other Insurance?

• Employer coverage: You don’t need to enroll on a Medicare drug plan if you’re enrolled on a group plan with creditable drug coverage. It’s important to call your benefits administrator before making any changes or consult with us.
• COBRA: If you recently lost employer’s coverage, you can enroll on Medicare Part B instead of taking COBRA. You’re granted a special election period to join a drug plan.
• Medicare Supplement: It’s encourage to enroll on a Medicare drug plan because Medicare Supplement doesn’t cover prescriptions.
• Medicaid: If you’re eligible for both Medicare and Medicaid, Medicare normally enrolls you automatically on a stand alone drug plan but you can decide to enroll on another stand alone plan or Medicare Advantage with a built drug plan.
• Health Insurance Marketplace: The Marketplace is for Anyone that doesn’t qualify for coverage so this doesn’t apply to Medicare beneficiaries.

Veteran’s Benefits

Veterans Affairs (VA) may cover your prescriptions but you can also join a Medicare Prescription Drug Plan but if you do, you can’t use both types of coverage for the same drugs.

TRICARE

Majority of people that have TRICARE has prescription drug benefits. If you have TRICARE, you don’t need to join a Medicare drug plan.

Here’s some useful tips for better Medication Management.

Medications are important with our day-to-day life. Whether you just wake up with a headache at times or you’re handling a chronic condition, over-the-counter medications and prescription drugs should be on top of your priority list. And being knowledgeable on medication management is beneficial not only for you but for your entire family.

• Purchase generic drugs to save money.

  Generics contain the same active components that are on branded medications. This way, you’ll get the same treatment quality without spending too much.

• Use a pill box to organize your medications.

  This is an easy way to keep track of the medication name, time and frequency of your intake. This is practical most especially if you or someone in the family is taking meds on a regular basis.

• Ask your pharmacist.

  If you have questions on your meds, you pharmacist could definitely help you. They are the experts you can talk to with regards to drug side effects, dosage, adverse reactions and many more.

• Take advantage of the health benefits you could get from your health insurance plan.

  Most healthcare plans offer health services that are at no cost to you. This includes flu shots and other immunizations, screenings and annual checkups.

• Set refill reminders.

  Medication management is mostly about making sure you take meds at the correct time, frequency and dosage. Set reminders could be a huge help most especially when you’re taking various prescription drugs all at the same time.

• Make the most of prescription mail-order opportunities.
  Who wouldn’t want their maintenance medications to be delivered directly to their home? Of course, we all want that time-saving and budget-effective services.

• Bring your medications list whenever you see a doctor.
  It is always best that your physician knows every single detail about the drugs you’ve been taking. This way, he’ll fully understand your health and be able to diagnose further.