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Part D: Information
on Prescription Drug Program Basics
Program began January
1, 2006.
Coverage of Medicare Part D benefits is provided by private
companies.
Medicare pays a share of the program costs.
Individuals entitled to Part A and/or enrolled under Part B are
eligible to enroll in Part D plans.
Part D plan coverage is provided through network pharmacies in the
Part D plans service area.
Part D plans commonly use a variety of prescription drug benefit
management tools, including:
- A formulary: A
list of drugs covered by the plan
- Co-pay tiers: A set amount for each prescription. Many plans
group drugs into 3 or 4 tiers with lower tiers costing less than
higher tiers, for example:
» Tier 1: Generic drugs
» Tier 2: Preferred brand-name drugs
» Tier 3: Non-preferred brand-name drugs
» Tier 4: High-cost drugs
By law, Part D plans
are permitted to cover any prescription drugs and biologicals that:
- Must be covered by
states that provide Medicaid prescription drug benefits
and
- Many Part D plans do not cover all of these drugs because in
some cases several similar drugs are available to treat the same
medical condition.
- Plans include the drugs they will cover on formularies that
are developed by pharmacists, doctors, and other experts.
Part D plan
formularies must include:
- At least two drugs
in each therapeutic category
- Generic and brand-name drugs.
By law, Part D plans
are not permitted to include the following under their Part D
covered benefits:
- Drugs for weight
loss or gain, fertility, cosmetic purposes, symptomatic relief
of cough and colds
- Vitamins
- Barbiturates*
- Benzodiazepines*
- Erectile dysfunction drugs (when used for sexual dysfunction)
- Non-prescription drugs
- Part B covered drugs
Part D plans are
permitted to offer supplemental benefits that cover drugs not
covered under Part D.
*At this time, plans
must cover benzodiazepines and barbiturates if used to treat
epilepsy, cancer, or a chronic mental health disorder
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