KBenefits Insurance Services
Insurance - Medicare - Retirement

Medicare Part D: Prescription


Rx Deductible:
The amount you must pay for health care or prescriptions, before Original Medicare, your Medicare drug plan, your Medicare Health Plan, or your other insurance begins to pay.  For example, in Original Medicare, you pay a new deductible for each benefit period for Part A, and each year for Part B. These amounts can change every year.


Initial Rx Coverage Level:
Once you have met your yearly deductible, and until you reach the plan's out-of-pocket maximum, you pay a copayment (a set amount you pay) or coinsurance (a percentage of the total cost) for each covered drug.


Rx Coverage Gap:
Starting January 1, 2011, if you reach the coverage gap (also called the "donut hole") in your Medicare prescription drug coverage, you will get approximately a 50% discount on covered brand drugs. Medicare has also increased its coverage of generic drugs for beneficiaries in the coverage gap so that beginning in 2011 you will pay less for generic drugs as well. The drugs eligible for the brand discount or the additional generic savings may change based on the information we have available.

Catastrophic Rx Coverage:
Once you reach your plan's out-of-pocket limit during the coverage gap, you automatically get "catastrophic coverage."  Catastrophic coverage assures that once you have spent up to your plan's out-of-pocket limit for covered drugs, you only pay a small coinsurance amount or a copayment for the rest of the year.


Prior Authorization (PA):
Prior authorization means that you will need prior approval from an insurance plan before you fill your prescription. If a drug has prior authorization, you will need to work with the plan and your doctor to get an exception.  Call your plan or visit their Web site to learn more about specific prior authorization requirements. Many prior authorization requirements can be resolved at the point of sale and don't require any additional information from your doctor. Knowing what the prior authorizations are before going to your doctor's office may save you time at the pharmacy counter.


Quantity Limit (QL):
For safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time. If the drug has a quantity limit restriction, you should contact the plan for more details. If you take one pill per day and the drug has a 30 day/month quantity limit, the impact will be minimal (i.e., you may not be able to refill the prescription until a few days before running out of pills). If you currently take 2 pills per day and the quantity limit is 30 pills per month, you would need to work with the plan to get authorization for the higher quantity.


Step Therapy (ST):
In some cases, plans require you to firs
you try one drug to treat your medical condition before they will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first.  If Drug A doesn't work for you, then the plan will cover Drug B. If a drug has step therapy restrictions, you will need to work with the plan and your doctor to get an exception.



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Christopher S. Kudryk

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