Prescription Drug Plans (PDP)
In certain situations, especially when you are on a supplement, you need to get an individual PDP. Even if you currently are not on any medication, or on inexpensive meds, you should still get a PDP. For one thing, you will avoid a late penalty if you do not get coverage when first eligible, but you also want to have coverage should you be put on an expensive medication in the future. There are many things to consider when looking at a PDP. It is best to seek assistance. Some of the variables are.
- Should you get a plan with a deductible?
- Is a higher premium plan better overall than the lower premium?
- You must make sure your medications are on the formulary.
- If you are on expensive medications, know how coverage is going to work in the coverage gap.
- Understand the different tier levels and what your medication should cost.
A brief description of how a PDP works is:
- There are different levels of coverage, known as tiers. Generally, the higher number tier, the more the cost is to you. Tier 1 and 2 are usually generic meds, Tier 3 and 4 are preferred and then non-preferred brand-name drugs. Most items on Tier 1 and 2 can have a $0 or low copay, while the upper tiers will have higher copays or a % of the price. Tier 5 usually consists of specialty items, which are expensive.
- Once the combined amount of your cost and the insurance companies reach a certain level, you reach a coverage gap in which you would normally pay a 25% coinsurance. Tier 1 and 2 items may be covered the same in the gap.
- If you should then reach the next level in combined cost, you would be in the catastrophic coverage phase. In this phase, you pay a 5% coinsurance or a reduced copay whatever is more. This level helps protect you from excessive drug cost.
- Most plans have a deductible. You would pay this amount before coverage would begin. The deductible usually does not apply to Tier 1 drugs and sometimes Tier 2 also.
- Beginning in 2023, The Shingles and TDap Vaccines are covered at a 0 copay. (Flu, Pneumonia and Covid vaccines are covered on Part B or Medicaid)
As you can see, drug coverage can be quite complex. It is highly recommended that you have someone who will help you, and clearly explain how this all works. There is a program called Extra Help, which can assist with your drug cost. For more information refer to the financial assistance section of this website.
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