St. Louis Medicare Part D: An Overview Of Premiums, Enrollment, And Penalties

Before 2006, Medicare didn’t offer any drug coverage, leaving people with no choice but to pay the out-of-pocket costs for prescriptions. However, it changed when George W. Bush introduced ‘Medicare Modernization Act’ in 2003. The law introduced Medicare Part D, which provides medication coverage to patients. Now, St. Louis Medicare Part D has become an essential need for people who intend to use common drugs or specific prescriptions in their healthcare routine.

Since it had become a valuable category of the Medicare program, nearly 45 million citizens of the United States got enrolled in Medicare Part D in 2019. Regarding the enrollment of Part A and Part B Medicare, we can expect a hike in the enrollment of beneficiaries for Part D in 2023.

So, what are the changes introduced in 2022 regarding the Part D plan?

In 2022, Medicare Part D has proposed changes that you must know regarding premiums, copays, and formularies. In addition, different private insurance companies are offering prescription drug plans. Therefore, the cost structures or the benefits will vary depending on the plan chosen under Medicare Part D. Approximately thirty formularies fall under Part D. The safe option is to compare plans according to your medication regimen. As a result, you can figure out what plan best suits your healthcare needs.

Some big plans for Medicare Part D in 2023 are as follows:

Wellcare Value Script (PDP)
Humana Walmart Medicare Part D (PDP)
Silverscript SmartRX (PDP)

This article outlines all you need to learn about Medicare Part D: premiums, deductibles, penalties, formularies, and other significant aspects that can make enrollment easy. Let’s start with a brief introduction to a drug plan.

What Is St. Louis Part D Medicare?

Already enrolled in the Medicare program but don’t have drug coverage? Medicare Part D can help you cover drug expenses that aren’t covered in the Original Medicare Program. It’s an optional Medicare program offered by private insurance companies rather than any federal or state office. Beneficiaries enrolled in the Medicare program are eligible for the Part D plan and even can opt for this plan with Medicare Advantage Plan.

However, if a person doesn’t decide to get enrolled when he is first eligible, he might end up paying the penalty for this plan added to its monthly premium.

You can’t rely on the extra creditable prescription drugs (offered by the union or an employer). Hence, choosing a Medicare-approved program that comprises a Part D plan won’t just help you cover drug expenses but also offer a wide range of drugs that fall into protected classes, like drugs needed to treat HIV/AIDS.

Furthermore, this plan intends to lower the cost of brand-name and generic prescription drugs at participating pharmacies. Before understanding the enrollment process, let’s first put a glimpse at generic prescription drugs:

What Is A Generic Prescription Drug?

The Food and Drug Administration (FDA) defines generic drugs as similar to brand-name drugs that function in the same following way:

Route of administration
Dosage form
Performance characteristics
Intended use
Safety
Strength
Quality

The FDA approves generic prescription drugs only if they use the same active ingredients used in the brand-name prescription drugs. So if you’re a regular user of GPD, consult your prescribers or doctors for more information about generic drug coverage.

How To Enroll In Medicare Prescription Drug Coverage Plan?

Following are the two main programs that aid in getting PDPs:

Medicare Prescription Drug Coverage Plan

Medicare Part D provides drug coverage to Original Medicare, Private Fee-for-Service Plans, Medicare Cost Plans, and Medical Savings Account Plans. To join a different drug plan, a beneficiary must enroll in Part A and Part B Medicare.

Note: To enroll in any Medicare health program with drug coverage, a beneficiary must be a U.S citizen or should be lawfully present in the United States.

Medicare Advantage Plan (Part C)

Medicare Part C, also known as Advantage Plan, is a complete package that comprises Part A, Part B, and drug plans. You can claim Part D only if you have enrolled in Part A and Part B Medicare. This plan has different categories, some of which don’t support drug coverage; therefore, you must consult your insurance network before choosing any drug plan.

Steps To Remember During Enrollment

Before enrollment, it’s essential to consult your insurance network. Then, once you decide on your plan, follow the steps mentioned below:

First, enroll yourself on the plan’s website or on the Medicare Plan Finder.
Then, fill out the paper enrollment form.
Remember to keep your Medicare card number safe, including the date of registration for Part A and Part B Medicare.
Call the plan to get your coverage started.

Options For Enrollment Period

To enroll in Medicare, a person can consider several options for the enrollment period, including:

Once people enroll in the Medicare program after turning 65, they become eligible to join Part D Plan within 63 days of their birth month. They must find any other enrollment period if they cannot register during this time.
The open enrollment period is another choice that starts from October 15 to December 7, effectively beginning the coverage period from January 1 in the following year.
If a beneficiary plans to drop an Advantage plan and switch back to Original Medicare with an independent Part D plan, he should enroll between January 1 to March 31.
A one-time Special Enrollment Period (Extra Help) allows the beneficiaries to enroll from December 8 to November 30. This opportunity is only open to people who meet the eligibility criteria.

How To Switch In The Desired Drug Plan?

Depending on your healthcare needs, you can switch to a new Medicare Part D plan between the enrollment periods mentioned above. A beneficiary doesn’t have to pay the cost of the old Medicare plan when he starts paying for the new plan. Furthermore, you don’t need to cancel the enrolled plan before switching to a new one. After registering, your insurance network will send you a letter about new drug plan coverage details and will automatically begin your new plan.

Plan D Premiums, Deductibles, & Co-pays

Medicare Part D plan has different cost structures, deductibles, monthly premiums, and copays. The exact cost depends on the need of the individual’s plan. Let’s take a look at how the Plan D cost structure works:

Premium Of Plan D

In 2022, the average monthly premium set for Medicare Plan D was $33. Approximately, it’s expected to be raised by 8% in 2023. A person might also pay an extra amount from their income in addition to the Plan D premium called “Part D- income-related monthly adjustment amount.” Not everyone is obliged to pay an additional amount, but the beneficiaries who have higher income will pay an extra amount during enrollment in the Part D plan. Furthermore, a person enrolled in MAPD also has to pay the additional amount with the monthly premium.

The two common ways to pay your Medicare premiums are bank deductions or mailing a paper bill. A beneficiary can also pay a monthly premium from the ‘Social Security Payment.’
Remember, each company offers different premiums for the drug plans depending on the medication needs of the beneficiary. That’s why STL Medicare Benefits help clients to explore plans that best suit their situation.

Deductibles Of Drug Plan

The deductible is the common term used in Medicare healthcare plans. The beneficiary pays the max-out-of-pocket amount before the enrolled plan covers the cost of drug prescriptions. In 2022, the maximum deductible is not more than $480. Some Medicare Part D Plans don’t have deductibles, which means you’re only obliged to pay coinsurance or copayment for the chosen prescription drugs. A beneficiary can pay lower deductibles only if his Medicare Part D Plan tier has the lower number.

Copays Or Coinsurance Of Drug Plan

Copay or coinsurance in a drug plan is the amount paid after deductibles. The coinsurance amount may vary depending on the level of tiers assigned to your program category. Another condition is using brand-name drugs, but your plan might offer generic drug coverage.
Under Standing Drug Benefit, once a beneficiary and the plan spend $4,430 on the drugs, they’ll not pay more than 25% of the coinsurance for the prescription drug. It may continue until beneficiary spending reaches $7,050 in 2022. After hitting this threshold, the enrollee will pay a $3.95 copay for generic drugs and $9.85 for brand-name drugs.

Donut Hole, Also Known As Coverage Gap. How Does It Work?

The donut hole, also known as the coverage gap, has been considered the most challenging part of the Medicare Part D Plan. In the past, it has raised concerns of beneficiaries to a great extent, but the good news is that the ‘Donut hole’ has been closed by ACA in 2020.

However, the way Medicare Drug Plans are designed, it’s essential to understand the ‘Donut Hole’ concept that plays a vital role in learning about drug coverage.

When Donut Hole closed in 2020, it forced beneficiaries to pay higher costs for the drug prescriptions until they reached the catastrophic period, after which the cost of drugs decreased to a certain level.

The Donut Hole is the coverage gap between the initial period and the catastrophic period in which a beneficiary has to pay deductibles. Also, the plan pays for the drugs only when their spending increases to enter the Donut Hole.

What Happens When A Beneficiary Reaches Donut Hole?

After reaching Donut Hole, beneficiaries start paying 100% for their drugs and would’ve to continue until their spending touches the Catastrophic Period.

Donut Hole Plan D Model In 2022

Each year, the cost amount for a drug plan varies and includes deductibles. The federal government sets a maximum deductible amount for Medicare Part D Plan. It also establishes a dollar amount for the thresholds where Donut Hole begins and ends. Here’s how Donut Hole works in 2022:

Deductible In Donut Hole

An enrollee has to pay $480 for the drug prescription coverage after joining Part D Medicare. This cost is known as the deductible in the Donut Hole.

Initial Coverage Level

Once the deductible is met during the initial coverage level, a beneficiary pays coinsurance or copayments. The plan also contributes its shares for the drugs until the combined cost reaches (including deductibles) $4,430.

Starting Donut Hole Period

What should you do next when you and your plan successfully pay the $4,430 amount? First, it indicates that you’ve entered the Donut Hole! Earlier in 2011, an enrollee had to pay 100% for the drug prescriptions, but now that ACA has closed this period, you’ll have to pay 25% of the cost of drugs in the Donut Hole period.

Ending Donut Hole Period

How to end the Donut Hole period? A beneficiary can only conclude this period if his max-out-of-pocket cost reaches $7,050 in 2022. Annual cost spending may include yearly deductibles, copays/coinsurance, and drug discounts offered by manufacturers.

Catastrophic Coverage Stage

Paying a small percentage of the drug cost after the Donut Hole period is called Catastrophic Coverage Stage. This stage starts when you and your plan reach the amount of $7,050. Once you reach this figure, your plans take further responsibility for paying drug costs for the remaining year.

Formulary & Tiers Coverage In The Part D Medicare

Medicare Part D classifies itself into formularies and tiers that a beneficiary picks according to his healthcare needs. For example, each insurance company offers unique Part D plans containing a list of drug prescriptions called ‘Formulary’.

Regarding generic drugs and brand-name prescriptions of the Part D plan, the formulary includes at least two drugs in the most prescribed categories by doctors. Usually, plans can choose two drugs per drug class that helps treat different medical conditions.

It’s possible that a formulary of your particular plan might not contain the desired drug. However, if any of the mentioned drugs in the formulary are not helpful to your medical condition, you can always ask insurance providers for an exception or at least choose a formulary that contains medications with the same formula.

How To Deal With The Unsafe Drugs?

The Food and Drug Administration has the authority to check the quality of the medicines that are unsafe for the health. Therefore, private insurance companies who offer Medicare Part D plans must remove drugs with hazards and immediately add generic drugs instead. Furthermore, when a plan decides to add new generic drug prescriptions to the formulary, it can also change the cost or coverage rules for the brand-name drug prescriptions.

If your drug isn’t included in the current plan formulary, you’re supposed to pay the total cost instead of breaking it into coinsurance or copayments unless your plan qualifies for the exception. Unlike brand-name drugs, generic prescriptions are the best choice to save max-out-of-pocket costs.

How Do Drugs Classify Into Tiers And Levels In The Drug Plan?

Medicare Part D plans consist of an independent formulary on which you can place drugs into different levels called tiers. Each tier contains a distinctive cost structure, like a specific drug identified in the lower tier will cost less than the drugs added to the higher tier.

Consider this example of Medicare Part D tiers that will help you make a better choice for your personal drug plan:

Tier 1—lowest copayment: most generic prescription drugs
Tier 2—medium copayment: preferred, brand-name prescription drugs
Tier 3—higher copayment: non-preferred, brand-name prescription drugs
Specialty tier—highest copayment: very high-cost prescription drugs

In some situations, a prescriber or a doctor can ask for an exception in the formulary when he thinks that a lower generic prescription drug might not work the same way as the drug added in the higher tier.

Late Enrollment Penalties Of Part D Medicare

Late enrollment penalties are due when you don’t enroll in the Medicare Part D plan during the initial 63 days of your enrollment period. Another scenario is when you don’t have creditable drug coverage for your healthcare needs. So,

How does Medicare calculate the late enrollment penalty?

Medicare multiplies the 1% base premium of Part D ($32.74) with the number of uncovered months. In addition, it rounds the monthly premium closely to $10 and further includes this amount in the Part D Medicare premium.

Let’s take a brief example of a late enrollment penalty and how you can calculate it in the future:

For instance: If someone didn’t get the chance to enroll in Medicare Part D for seven months, the penalty would be 7% of $32.74, which is $2.29. Medicare rounds $2.29 to $2.30 and adds it to the future monthly premium of Part D.

4 Reasons You Must Sign Up For Part D Medicare

Unexpected diseases can be alarming and cost way too much if not attended to with the right healthcare insurance plan. Therefore, enrollment in Part D Medicare is as essential as enrolling yourself in Part A and Part B Medicare.
Here are four significant reasons why Part D Medicare is worth enrolling in:

Enroll When Your Employment Health Coverage Period Ends

Do you have a healthcare plan that covers your regular medication expenses? Joining prescription drug coverage is essential for many older adults. Unfortunately, most employers don’t offer healthcare coverage and its benefits after retirement. Enrolling in the drug plan will help you avoid gaps in coverage and save money.

Part D Works To Ensure Protection For The Future

The financial burden and hefty prescription drug costs become unmanageable when you don’t have healthcare insurance. To avoid such situations, Part D is the best suitable choice for ensuring the protection of your future. Not enrolling in coverage can pay hundreds or even thousands of dollars for a particular medication. While in the enrollment period, beneficiaries get an opportunity to choose tiers of prescription drugs that can help them cover regular medication expenses.

Joining Part D For Getting Affordable Flexible Plan Options

Since private insurance companies offer Part D Medicare, you’ve got plenty of plans to choose from because all plans fulfill your medication needs in one way or another. However, each plan may differ in cost and coverage. Based on your service area, some drug plans cost as little as $15.

But what if the person rarely uses drug prescriptions in their daily routine?

A beneficiary can always choose plans with lower premiums to get the drugs needed during treatment for everyday ailments. However, someone who depends on the specific medication can look for a plan that charges lower deductibles or pick a lower-cost tier to cover drug prescription expenses.

Choose A Drug Plan to Avoid Late Enrollment Penalties

At the time of retirement time or late enrollment penalties, avoid all unnecessary penalties by enrolling yourself in the initial period.

Note that delaying enrollment will leave you no choice but to pay extra costs added to your monthly premiums. Therefore, enrolling in the Part D plan, when first eligible, will help you avoid late enrollment penalties.

Ready To Sign Up For St. Louis Part D Medicare? Let’s Get It Done With STL Medicare Benefits!

STL Medicare Benefits value your healthcare concerns. To help you get the best drug prescription plan, we compare cost structures, offer flexibility in drug prescription plans and coverages, share trustworthy referrals, and protect you from late enrollment penalties.

Above all, we keep updated information regarding generic and brand-name drugs to help you choose better medication formularies in your plan.
Sometimes Medicare drug plans aren’t easy to get through, including cost tiers and coverages; with STL Medicare Benefits, you get clear instructions that best suit your drug prescription needs.
Do you want to get access to the right Medicare drug plan? Request an Appointment to get STL Medicare Benefits consultancy on https://stlmedicarebenefits.net/