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MEDICARE PRESCRIPTION DRUG PLANS (PART D)

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WHAT IS MEDICARE PART D (Prescription Drug Plans)?

  • Medicare Part D is the prescription drug coverage for Medicare
  • Helps lower the cost of prescription drugs
  • Offered by private insurance companies that are approved by Medicare

  • WHICH DRUG PLAN IS RIGHT FOR ME?

    Do you need Medicare part D help in choosing the right plan for your needs? You need to know that:

    • The Medicare drug plan with the lowest premium does not necessarily equate to lowest annual total cost
    • Medicare Sharks will help you find the best drug plan that fits your needs and budget according to your specific prescription drug list.
    • Every drug plan has a different premium along with a deductible and copays.
    • Each drug plan has a different list of drugs that are covered under their “Formulary & Tiers.”
    • Your actual drug plan costs will vary depending on factors such as the drugs you use, the plan you choose, the pharmacy you use, whether the drugs you use are on your plan’s formulary, etc.
    • Call Medicare Sharks to discuss your regular prescription list and we will do a quick search to compare every drug plan’s formulary to find the best overall option that will provide the lowest annual total cost. We offer Medicare Part D help.

    Let Medicare Sharks do the hard work for you!

  • WHAT ARE MY OUT-OF-POCKET COSTS?

    In 2025, the yearly out-of-pocket drug costs will be capped at $2,000.  Once you reach this limit, you won’t have to pay a copay or coinsurance for covered part D drugs for the rest of the calendar year.  (Premiums & Deductibles are not counted towards the $2,000 maximum)

    In 2025, the Medicare Prescription Payment Plan (MPPP) will help you manage your expenses  but it does not save you money or lower your drug costs. If you select this option, you will get a bill from your plan each month to pay your drug costs.  This is designed to spread your drug costs across the year, so you pay close to even payments each month.

    In 2025, there is no longer the “donut-hole” phase.

    In 2025, plans can’t charge more than $35 for covered insulin for a 1-month supply and you don’t have to pay a deductible for insulin.

  • HOW DO I REDUCE MY DRUG COSTS?

    • Talk to your doctor about prescribing lower cost alternatives when possible.
    • Use generics and over-the-counter options as an alternative to brand name medications.
    • Use your plan’s preferred pharmacy network or use your plan’s mail-order pharmacy and refill medications for a 90-day supply.
    • Use free discount program cards/coupons such as www.GoodRx.com
    • Research a specific drug manufacturer’s Prescription Assistance Program

PLANS MAY HAVE COVERAGE RULES FOR CERTAIN DRUGS:

  • 1. PRIOR AUTHORIZATION:

    You and/or your prescriber must contact your plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it. Plans may also use prior authorization when they cover a drug for only certain medical conditions it is approved for, but not others. When this occurs, plans will likely have alternative drugs on their list of covered drugs (formulary) for the other medical conditions the drug is approved to treat.

  • 2. QUANTITY LIMITS:

    Limits on how much medicine you can get at a time.

  • 3. STEP THERAPY:

    You may need to try one or more similar, lower-cost drugs before the plan will cover the prescribed drug.

  • 4. PRESCRIPTION SAFETY CHECKS AT THE PHARMACY:

    (including opioid pain medicine): Before the pharmacy fills your prescriptions, your Medicare drug plans and pharmacy perform additional safety checks, like checking for drug interactions and incorrect dosages. These safety checks also include checking for possible unsafe amounts of opioids, limiting the says supply of the first prescription for opioids, and use of opioids at the same time as benzodiazepines (commonly used for anxiety and sleep). Opioid pain medicine (like oxycodone and hydrocodone) can help with certain types of pain but have risks and side effects (like addiction, overdose, and death). These can increase when you take opioids with certain other drugs, like benzodiazepines, anti-seizure medications, gabapentin, muscle relaxers, certain antidepressants, and drugs for sleeping problems. Check with your doctor or pharmacist if you have questions about risks or side effects.

  • 5: DRUG MANAGEMENT PROGRAMS: MEDICARE DRUG PLANS 2025

    Medicare drug plans 2025 and help plans with drug coverages have a program in place to help you use these opioids and benzodiazepines safely. If your opioid use could be unsafe, for example, fie tp getting opioid prescriptions from multiple doctors or pharmacies, or if you had a recent overdose from opioids, your plan will contact the doctors who prescribed them to you to make sure they’re medically necessary and you’re using them appropriately.

    If your plan decides your use of prescription opioids and benzodiazepines may not be safe, the plan will send you a letter n advance. This letter will tell you if the plan will limit coverage of these drugs for you, or if you’ll be required to get the prescriptions for these drugs only from one doctor or the pharmacy you select. You and your doctor have the right to appeal these limitations if you disagree with the plan’s decision. The letter will also tell you how to contact the plan if you have questions or would like to appeal.

If you or your prescriber believe that your plan should waive one of these coverage rules, you can ask for an exception.

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