What is Medicare Part D?

Each year, Medicare beneficiaries are given the opportunity to select a new plan for the upcoming year during the Open Enrollment Period. This year, Open Enrollment begins on October 15 and will run until December 7, 2024 – for most people, this will be the only opportunity to make changes to the plan that will cover them in 2025.

Medicare Part D provides prescription drug coverage for more than 53 million Americans, including seniors and those affected by chronic conditions like lupus. Choosing the correct plan for your specific, individual circumstances is a critical part of your health.

Below, we’ve answered 10 of the most common questions Part D beneficiaries with lupus may have during Open Enrollment. Whether you were satisfied with your plan in 2024 or not, you should take advantage of this time to make sure you are set up for success in 2025. Additionally, the Foundation has created a Medicare Part D Open Enrollment Guide that provides a complete overview of the Open Enrollment process.

1. Can you explain the different parts of Medicare (A, B, C, D) and do I really need Part D?

   There are four parts of Medicare: Part A, Part B, Part C and Part D. Generally, the different parts of Medicare help cover specific services. Part A provides inpatient/hospital coverage. Part B provides outpatient/medical coverage, including some infused therapies received in a doctor’s office or infusion center. Part C offers an alternative way to receive your Medicare benefits or sometimes called a Medicare Advantage plan. Part D provides prescription drug coverage. Part D coverage is important for lupus patients because it provides coverage for your medications to manage your lupus and other medications. Even if your medications aren’t currently expensive, you should consider enrolling in Part D because you never know when your coverage needs may change. You are only able to enroll in Part D coverage during the Open Enrollment period once a year. 

2. I’m new to Medicare, do I have to enroll in Part D coverage? 

   When you have a chronic illness, like lupus, it is important to have coverage for your life-saving medications and not enrolling when you’re eligible can result in paying more out of pocket. If you don’t sign up for a Part D plan when you are first eligible to do so, you are subject to a late enrollment period. The late enrollment period penalty is equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit. 

3. My plan was fine in 2024 – why would I shop for a different plan?

   All plans will make changes going into 2025 – some of those changes might not affect you, but it is worth your time to use the Medicare Plan Finder to see what the changes are. Possible changes that could affect you include higher premiums, deductible amount, copay and coinsurance amounts, and perhaps most importantly, what medications are on the plan’s formulary. Just because your plan covered a medication in 2024 does not guarantee that they will again cover it in 2025. Finally, new this year, Medicare Part D prescription drug plans will have an out-of-pocket maximum of $2,000. Medicare Part D beneficiaries can also opt in to the Medicare Prescription Payment Plan (MPPP)—a new program that lets you pay for prescriptions in monthly installments allowing you to spread out your costs through the year.

4. How do I know how my plan has changed?

   You should have received a letter from your current plan called an Annual Notice of Change / Evidence of Coverage by mid-October. This letter explains some of the important changes to your plan, including changes to its name, the premium amount, the drugs it covers and their cost, and any added restrictions that may limit your access to medications. It is very important to read this letter as these changes can have a large impact on the cost of your drugs. If you have not received the Annual Notice of Change/Evidence of Coverage letter, call your plan immediately.

5.  If I switch drug plans during Open Enrollment period, do I need to notify anyone of the change?

   Once your new coverage begins in January, you should notify your pharmacy where you fill your prescriptions so that they can update your records with your new plan information. When you enroll in a new drug plan, it disenrolls you from your previous plan so you do not need to contact the previous plan to drop that coverage. 

6. I’m just choosing the plan with the lowest premium, right?

   Not necessarily! Your premium is the most predictable of all your drug costs – it is the amount of money you will pay to the plan every month, regardless of what drugs you are prescribed. However, do not just choose the plan with the lowest premium – instead, use the Plan Finder to look at each plan’s estimated total drug and premium cost so you have a clearer understanding of your total out-of-pocket costs. In some cases, your total annual costs may be lower if you select a plan that has a higher monthly premium.

7. How can I avoid prior authorization or step therapy requirements? 

   We know that many insurance plans impose utilization management requirements that can make it harder for people with lupus to access their medications. In Part D, many plans will have step therapy or prior authorization requirements, but that information will always be shared on the Medicare Plan Finder. When using the Plan Finder, expand the section titled View more drug coverage under Other drug information – here, you’ll see what requirements might exist for the medications you’re currently taking. If you can’t find a plan without these requirements, talk to your doctor about how they might affect you.

8. What is a preferred pharmacy and how can it help me lower my costs?

   Most Part D plans will have a working relationship with a pharmacy or pharmacy chain and deem it their “preferred pharmacy.” In practice, this may mean that you’ll save money by getting your medications through their preferred pharmacy as a result of lower copays or coinsurance. When you review plans using the Medicare Plan Finder, you’ll be given the option to enter the pharmacy you usually use and find out if it is “preferred” by each plan – if its not, you may save money by using a different pharmacy in your area, but you should only plan to use pharmacies that you can reliably and conveniently get to when necessary. 

9. How can I save money on prescription costs?

   If you still need help paying for your prescriptions, even with a Part D plan, there are a few different options. Extra Help is a Medicare program to help people with limited income and resources pay Medicare Part D premiums, deductibles, coinsurance and other costs. If you do not get Extra Help automatically, you can apply if you meet eligibility criteria. 

The Lupus Foundation of America has created Open Enrollment materials that provide an overview of the Open Enrollment process and answers several other questions you may have regarding healthcare plans and the new updates to Medicare Part D. If you have additional questions about Medicare Part D or Open Enrollment, reach out to our health education specialists.