Last Updated on
October 6, 2016
As a Medicare beneficiary in Texas, you’re eligible to enroll in a stand-alone Medicare Part D Prescription Drug Plan. Costs and availability for Medicare Prescription Drug Plans vary, and you are likely to have several options from which to choose your prescription drug coverage. Most plans require you pay a monthly premium, annual deductible, and copayment or coinsurance.
Medicare Part D is the federal program designed to offer Medicare beneficiaries like you prescription drug coverage, whether they live in Texas or elsewhere. You don’t receive your prescription drug coverage directly from Medicare. Instead, you receive these benefits from private insurance companies contracted with Medicare to offer prescription drug coverage to Medicare beneficiaries.
In Texas you have a choice in your selection of insurance plans providing Part D prescription drug coverage. Two basic types of plans exist. Depending on other choices you’ve made about your Medicare coverage, one of these two types is likely to be a good fit, providing valuable coverage to help pay some of your medication costs not covered by Original Medicare.
One way you can receive Medicare Part D prescription drug coverage is to enroll in a Medicare Advantage Prescription Drug plan, which combines health and prescription drug coverage into a single plan. Medicare Advantage Prescription Drug plans must offer at least the same level of health coverage as Original Medicare Part A (hospital insurance) and Part B (medical insurance) provide. Many offer additional health benefits that Original Medicare does not have—such as routine dental, vision, or hearing—and prescription drug coverage. To sign up for a Medicare Advantage Prescription Drug plan you must have Medicare Part A and Part B.
Another way you can receive Medicare Part D prescription drug coverage is to enroll in a stand-alone Medicare Part D Prescription Drug Plan. If you have Medicare Part A and/or Part B you can enroll in a stand-alone Medicare Part D Prescription Drug Plan and receive prescription drug benefits to complement your health benefits. You also may be able to add prescription drug coverage from a Medicare Part D Prescription Drug Plan if you are enrolled in a Medicare Advantage plan that does not provide prescription drug coverage. To choose this option, you must have Medicare Part A and/or Part B.
Each Medicare Part D Prescription Drug Plan in Texas has a formulary. A formulary is a list of covered prescription drugs. The formulary may change at any time and you will receive notice from your plan when necessary. Typically a Medicare Part D Prescription Drug Plan organizes the medications in its formulary into coverage categories called “tiers”. Each tier has a designated out-of-pocket cost (e.g., copayment or coinsurance amount). The top tier includes the most expensive drugs, and the bottom tier lists the most affordable medications. If your doctor determines that a drug in a higher tier is medically necessary for your treatment instead of a similar drug in a lower tier, you or your doctor can ask your plan for a tiering exception so that you can receive the benefit of a lower copayment for a higher tier medication.
Most Medicare Part D Prescription Drug Plans in Texas (as in other states) include brand-name prescription drugs and generic drugs in their formularies. The Food and Drug Administration (FDA) defines generic drugs as having the same active ingredients as brand-name drugs, at the same strength, dosage, and with the same method of administration. The FDA also requires that generics are tested to ensure they have the same results as brand-name prescription drugs. Generic drugs often cost less than the brand-name versions, and that can result in significantly lower out-of-pocket expenses. If a generic drug is not available, your Part D Prescription Drug Plan may allow you to substitute it with a similar generic drug used to treat the same condition. Be sure to discuss all prescription drug options with your doctor before you make changes to the medication you take.
If you enroll in a Medicare Part D Prescription Drug Plan Drug Plan, you continue to pay any applicable Part A and/or Part B premium(s) to remain enrolled in Medicare. You may also have a separate monthly premium you pay to the Medicare Part D Prescription Drug Plan in exchange for prescription drug benefits.
Generally, the prescription drug coverage provided by Medicare Advantage Prescription Drug plans share formulary characteristics described above.
You can enroll in a Medicare Part D Prescription Drug Plan when you qualify for Medicare, and during certain enrollment periods.
Timing is important. If you go without creditable drug coverage (that is, prescription drug insurance that is at least as good as Medicare Part D coverage) for 63 days or more after your Initial Enrollment Period ends, you may be liable for a late-enrollment penalty. The Medicare Part D late-enrollment penalty is calculated using 1% of the national base beneficiary premium and the number of full months you were eligible for Medicare Part D but didn’t enroll. This amount is then added to your Medicare Part D monthly premium. The national base beneficiary premium may increase each year, which means your late-enrollment penalty may also increase annually.
Whether you are interested in signing-up for a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, it’s to your benefit to shop and compare. Many plans offering Medicare Part D prescription coverage are available in Texas, not all may be available where you live. You can narrow your search by entering your zip code in the eHealth plan finder on this page.
Also, plans offering Medicare Part D prescription coverage have different costs. Premiums, deductibles, copayments, and coinsurance are likely to vary. Also formularies, the lists of covered prescription drugs, may vary. So it’s important to check to see if your medications are on the plan’s formulary and, if so, on which tier.
If you are currently enrolled in a Medicare Part D Prescription Drug Plan, it’s a good idea to review your coverage on a yearly basis to be aware of any changes. Medicare Part D Prescription Drug Plans in Texas and the rest of the United States are allowed to change their premiums, copayments, deductibles, and formularies each year and you will receive notice of these changes in the Annual Notice of Changes and Evidence of Coverage the plan mails you in the fall before the new benefits are effective the following January 1st.
See the following pages for additional information about Medicare in Texas: