To get Medicare coverage for your prescription drugs, you must choose and join a Medicare drug plan. Regardless of how a Medicare drug plan decides to offer this coverage, there are some key factors that may vary.
For most Virginians, cost is the main factor in choosing a Part D drug plan. The cost of a plan is determined by the following elements:
- Premium: This is the monthly cost you pay to join a Medicare drug plan. Premiums vary by plan.
- Deductible: This is the amount you pay for your prescriptions before your plan starts to share in the costs. Deductibles vary by plan.
- Copayment/Coinsurance: This is the amount you pay for your prescriptions after you have paid the deductible.
In some plans, you pay the same copayment (a set amount) or coinsurance (a percentage of the cost) for any prescription. In other plans, there might be different levels or “tiers,” with different costs. (For example, you might have to pay less for generic drugs than brand names. Or, some brand names might have a lower copayment than other brand names.) Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.
Other factors to consider in choosing a Part D plan:
- Formulary: This is the list of drugs that a Medicare drug plan covers is called a formulary. Formularies include generic drugs and brand-name drugs. Most prescription drugs used by people with Medicare will be on a plan’s formulary. The formulary must include at least two drugs in categories and classes of most commonly prescribed drugs to people with Medicare. This assures that people with different medical conditions can get the treatment they need.
- Prior Authorization: Some drugs are more expensive than others even though some less expensive drugs work just as well. Other drugs may have more side effects, or have restrictions on how long they can be taken. To be sure certain drugs are used correctly and only when truly necessary, plans may require a “prior authorization.” This means before the plan will cover these prescriptions, your doctor must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered.
- Coverage Gap: If you have high drug costs, you may consider which plans offer the best coverage. When your drug costs reach an initial coverage limit, then you pay 100 percent of your prescription costs. This is called the coverage gap—or “donut hole.” In 2012, the hole begins at $2,930 in total drug costs and ends when you’ve spent $4,700 out-of-pocket. Part D enrollees will continue to receive a 50 percent discount on the total cost of the brand-name drugs while in the donut-hole; and they pay a maximum of 86 percent copay on generic drugs while in the gap.
The list below contains the highest rated Medicare Part D prescription drug plans in the state of Virginia. It is for informational purposes only and some listings may be inaccurate or missing. The list was provided by the Centers for Medicare and Medicaid Services (CMS), but due to the variance in plans based on county, city, and region, some options may not be available in your location.