MEDICARE PRESCRIPTION DRUG PLAN (PDP)

Texas Prescription Drug Plan considerations

If you’re interested in a Texas Medicare drug plan you may want to weigh the benefits of joining. Depending on your situation, you will evaluate the best plan for your drug needs today. The Texas private insurance companies do not have to offer identical benefits from one Medicare drug plan to another. Since all plans meet the minimum guidelines set by Centers for Medicare and Medicaid Services, the rest is up to you to determine what is best for your situation. Assessing the premium and expenses, plan detail and where you will go to get your medication are part of this important decision.

Premium and Expenses
•The premium will remain constant for the plan you pick during the calendar year that you enroll.
•The drug expenses, however could change depending on the plan selected. You may have a deductible that needs to be satisfied before your copayment or coinsurance beings. Or, it may be in your best interest to join a plan that does not have a deductible and from the start you have co-payments or coinsurance. In other plans, there might be different levels or "tiers" with different costs. Generally, you pay less for a generic drug tier then brand drugs. Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.

Plan Detail

•What is covered in the Medicare drug plan is called a formulary. Most drugs will be on Medicare plan's formulary which includes generic drugs and brand-name drugs.
•Some drugs require prior authorization because they are more expensive or have more side effects, or have restrictions on how long they can be taken than a counter-part drug. Before the plan will cover these prescriptions, your doctor must first contact the plan to prove there is a medically necessary reason why you must use that particular drug for it to be covered.

Where to purchase medication
•Check to see if the local pharmacies in your area are contracted with the dug plan you are considering.
•If you are taking maintenance medication you may want to see plans that offer a mail-order program making convenient and cost-effective.

We all ask questions and finding the correct answers are essential. Here are a few answers to get us started exploring the Texas Medicare Prescription Drug Program (PDP).

Am I eligible for Texas Medicare prescription drug coverage?
If you have Medicare you can have Texas Medicare prescription drug coverage.

I am turning 65, when can I get Texas Medicare prescription drug coverage?
When you first become eligible for Medicare. You can join a Medicare drug plan during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. Your coverage will begin the first day of the month after you ask to join a plan. If you join during one of the 3 months before you turn 65, your coverage will begin the first day of the month you turn 65. Check directly with Medicare if you are seeking a PDP due to a disability.

How do the Texas Medicare prescription drug plans work?
The Medicare prescription drug plans provide much needed insurance coverage for prescription drugs you are taking. When you join, you will pay a monthly premium to the private insurance company that varies by plan you choose and pay a share of the cost of your prescriptions (deductible and/or, copayment and/or coinsurance). Costs and coverage will vary depending on the drug plan you choose.

What does the coverage offer?
Medicare prescription drug coverage helps you pay for your prescription drugs. Medicare prescription drug coverage will cover generic and brand-name drugs.

Am I required to join?
Enrollment is voluntary and joining is your choice. If you do join when you are first eligible, you will avoid paying a penalty as long as you have Medicare prescription drug coverage if you choose to join later. 

Will I be required to join a Prescription drug plan?
You are not required to join a drug plan; it is optional. If you need help covering costs for your drugs, then joining a Medicare prescription drug will help pay for your drugs. There are various plans to meet most any need. Even if your prescription drug purchases are infrequent now, consider joining. Joining when you are first qualified for Medicare coverage insures that you will not have a penalty to pay if you join at a later time. If you wait, the premium will be higher when you join because of the late fee penalty.

What does a Donut Hole mean?
The Medicare Part D coverage gap — informally known as the Medicare donut hole — is the difference of the initial coverage limit and the catastrophic coverage threshold, as described in the Medicare Part D prescription drug program administered by the United States federal government. After a Medicare beneficiary surpasses the prescription drug coverage limit, the Medicare beneficiary is financially responsible for the some or all of the cost of prescription drugs until the expense reaches the catastrophic coverage threshold.

How does Medicare prescription drug coverage work?
Original Medicare or a Medicare Supplement will not provide you with the prescription drugs you need. There are two means of getting Medicare drug coverage which are Medicare Advantage Plan with prescription drug coverage, (or other Medicare Health Plan that offers drug coverage) and a Medicare prescription drug plan (PDP). Plans will include a premium which will vary depending upon how much coverage they offer; some have deductibles and a coinsurance or copayment. These plans will help cover the generic and brand-name prescriptions you use now and in the future.

Why should I get Medicare prescription drug coverage?
Some individuals use extensive medications and now have the opportunity to save on expenses and others take few if any medications. In both cases a plan is favorable to put into place when you are eligible. It will give you peace of mind knowing that your expenses in most cases can be reduced.

Do I have any options for paying my Medicare drug plan premiums?
You have many options to pay for Medicare Prescription drug plan premium provided by the insurance carrier. Some payment options (depending upon insurance company): credit or debit card, billed each month from the plan, taken out of the person’s Social Security check each month, or deducted from a checking/savings account.

Can I get support to help me choose a Medicare prescription drug plan?
Receiving support is very helpful when trying to make a decision about a Medicare prescription drug plan. Contacting a member of your family or a close friend, or a caregiver can also assist you in making a decision. Other areas of support can be the tool Medicare provides to give you detailed plan information at Medicare Prescription Drug Plan Finder or by calling 1-800 MEDICARE (1-800-633-4227) TTY 1-877-486-2048. Also companies will be advertising their plan choices by mail, on television and in your local newspaper.

Will Medicare prescription drug plans (PDP) have preferred drug formulary?
All of the private insurance companies offering a PDP will have a preferred drug list. This is a specific list of drugs that the plan has selected to control cost and will be as effective as other drugs.

How does the a PDP work?
Each Medicare PDP will include generic and brand-name drugs that will be categorized into tiers that determine the rate paid by the insurance company and you, if applicable. The company generally classifies the drug into a formulary, which is simply a list of drugs covered by the plan which adheres to Medicare's requirements. If you need a drug that isn't on the list, or if one of your drugs is being removed from the list, you or your physician can appeal the decision.

Are some of my drugs covered under Part B?
Each Medicare PDP will include generic and brand-name drugs in a formulary and many of the medications you are already on should be covered. It is best to determine coverage before you sign up to ensure that you will be able to the majority of your medications at a reduced price.

What are the enrollment periods for Prescription Drug Program (PDP)?
You are eligible to join a Medicare Prescription Drug Plan when your turn 65 (or get Part B) and can elect to change prescription drug insurance companies and/or plans in Open enrollment every year for the next calendar year. There are exceptions to this rule, check with Medicare for your specific situation.

Are the medications that I am using be covered?
Medicare provides a great tool to look up detailed plan information at Medicare Prescription Drug Plan Finder or contact the provider. Before hand, make a list of all your current drugs including dosage, frequency and current monthly costs. Be sure to also determine if your favorite local pharmacy is in-network.

Will happens if one of my drugs needs "prior authorization?"
In some cases a medication will need a prior authorization. You can get specific information on how this is done by contacting your PDP insurance company.

What can I do if my medication isn’t on my plan’s formulary?
You can get specific information on how this is handled by contacting your PDP insurance company.

Should I check my medications in the Medicare Prescription Drug Plan Finder?
Yes, it is the best way to determine coverage and costs. Medicare provides a great tool to look up detailed plan information at Medicare Prescription Drug Plan Finder. Pull your list together before you enter your medications and the tool will indicate if the drug name that you entered is a Brand name, Generic, or Over-the-Counter drug.

Why is it best to use my Zip Code in the MedicarePrescription Drug Plan Finder?
By using your zip code in the tool it will allow you to see what the cost is in your geographic region.

What if I have a limited income and resources?
If you have limited income and resources you may qualify for financial help. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visit www.socialsecurity.gov to discover more information about financial help.

How can I find programs to help me with prescription drugs?
BenefitsCheckUp finds federal, state and private benefit programs available to help you save money on prescription drugs, health care, meals, utilities, taxes, and more. https://www.benefitscheckup.org

How can I save money on prescription drugs and other healthcare costs?
BenefitsCheckUp helps you make decisions about public and private programs available to help you save money on prescription drugs and other healthcare costs. BenefitsCheckUp is simple and free and includes up-to-date information of Medicare's Extra Help, State Pharmacy Assistance, Company Patient Assistance Programs and other important federal and state programs. https://www.benefitscheckup.org

How can I get Medicare Rx help?
If you have a limited income and assets, you can get Medicare Rx Extra Help paying for your prescription drugs through the Medicare Prescription Drug Coverage. To quickly find out if you are eligible for this Extra Help, answer just a few questions. We will also tell you if you are eligible for other government and state programs that can save you money on health care and prescription drugs. You may apply for the Extra Help after you complete a BenefitsCheckUp questionnaire. https://www.benefitscheckup.org


Formulary Finder for Prescription Drug Plans- https://www.medicare.gov/find-a-plan/questions/home.aspx

*Stand-Alone PDP includes 2.2 million enrollees receiving the limited income subsidy.

**Medicare Advantage includes 930,000 enrollees receiving the limited income subsidy. About 500,000 of these are Medicare-Medicaid beneficiaries.
www.hhs.gov/news/press/2006pres/05/20060510a.html

If you're currently not using a lot prescription drugs you will still want to consider joining a drug plan. If your usage changes in the future and you decide to enroll later, then you will have a penalty and your premium will be higher.