3 Medicare Part D Terms You Need to Know

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As we’ve said before, prescription drug coverage (Part D) is the most complex part of Medicare. From estimating specific drug costs to understanding the donut hole, there’s a lot to know and a lot to take in. Good news. Bobby Brock Insurance agents are well-versed in all areas of Medicare. And we’ve been helping clients since 1992! Here are three Part D terms you’ll hear about that you should become familiar with:

1.Prior Authorization

Some Medicare Part D plans might require prior authorization for coverage for specific medications. What does this mean? Before the drug plan covers a particular medicine, your doctor (or prescriber) has first to demonstrate your medical need for that drug and/or have fulfilled the prior authorization requirements for it. Prescription drug plans do this to ensure that medications are prescribed and taken correctly.     

Related Post: Medicare 101 – What You Should Know

2.Step Therapy

Step therapy is a kind of prior authorization. Most of the time, you have to first try a cheaper drug on the plan’s formulary (drug list) that has proven to be useful for most individuals with your condition — before you can “move up” to a more costly drug. This may involve you trying a similar generic drug that’s more affordable rather than an expensive, brand-name medication.

The cheaper drugs in the first phase are called Step 1 prescription drugs. 

Note: The formulary might change at any point. You’ll get a notice when it does.

However, if you’d already tried the cheaper drug and it didn’t pan out or if your prescriber believes you must take a more expensive medication, he or she can call the plan to ask for an exception. If the plan approves your prescriber’s request, they’ll cover the costlier drug — known as a Step 2 prescription drug.  

Medicare won’t cover Step 2 until you try Step 1 drugs first — unless an exception is received.

Related Post: Medicare Part D Plans for 2020

3.Quantity Limit

The third Part D term you should know is the quantity limit. Prescription drug plans may dictate limits on how many drugs they cover for a certain period. They set these boundaries for cost and safety purposes. 

For instance, a doctor may prescribe you a medication to take two tablets a day or 60 pills a month. If the plan’s quantity limit is 30 tablets each month for that medication, your doctor will have to contact the Medicare Part D plan to obtain authorization for a higher amount.

Please browse our website for more information about how Medicare Part D works.

Enroll in a Medicare Part D Plan

Did you know that if you’re enrolled in Original Medicare (A and B), you’re eligible for Part D? If you’re looking to get prescription drug coverage, contact an agent at Bobby Brock Insurance. You can also reach our Tupelo, MS office at (662) 844-3300.

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Justin Brock

President & CEO of Bobby Brock Insurance