Judge a Part D Plan by Its Drug List and Pharmacy Network Before You Enroll

A Medicare prescription drug plan, called a Part D plan, is sold by private insurers under Medicare rules. The brochure will name a premium and a headline benefit, but the monthly cost your parent actually pays depends on three papers the brochure rarely shows in full: the plan's drug list, the tier each drug sits in, and the pharmacy network the plan uses. Medicare publishes a plan finder on medicare.gov that pulls these papers together, and you should use it with the actual list of drugs in front of you rather than a sample.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

This piece covers stand-alone drug plans. It does not cover Medicare Advantage plans, which bundle medical and drug coverage and have their own network rules. The decisions about which medicines to take, and whether a substitute is appropriate, stay with the family, the physician and the pharmacist. The desk's job is to help you read the plan paper, not to compare the drugs themselves.

Start with the drug list

Each plan publishes a formulary, which is its list of covered drugs. Take the full list of prescriptions your parent uses, including any the physician has recently changed, and find each one by its exact name and strength on the formulary. Mark whether it is covered, whether it carries a restriction, and which tier it sits in. A drug that is missing from the formulary is not a small problem, because you will pay the full cost or go without unless the plan grants an exception.

Ask the plan how it handles requests for exceptions and how long a decision takes. Ask whether any drug on the list requires the plan's prior approval, or whether the plan requires a step through a different drug first. Those restrictions are where a plan that looks cheap on paper becomes expensive in practice. Get the answers in writing.

Read the tiers and the cost-sharing

Each tier carries its own copayment or coinsurance, and the tier is what sets most of the monthly bill for the drugs your parent uses. Compare the tier cost for each drug on the list rather than the average. Then add the deductible, if the plan has one, and ask the plan to show you how the cost-sharing works once the deductible is met. Medicare sets the outer limits on out-of-pocket cost for drug coverage, and the plan's documents describe how the limit applies to that plan. Read that section, not the summary.

Check the pharmacy network

Confirm that the pharmacy your parent uses is in the plan's network, and ask whether the plan offers a preferred pharmacy with lower cost-sharing. Ask the pharmacy directly whether it accepts the plan. The plan finder can tell you what the plan lists, but the pharmacy's answer is the one that decides whether the prescription is filled at the price you expect. If the pharmacy is outside the network, ask how the plan handles the difference before you enroll.

Ask how changes are announced

Plans may change their formularies during a year, and a change can move a drug to a higher tier or remove it. Ask the plan how it notifies members of formulary changes, and where those notices go. Keep the notices with the plan papers. A notice you never read is a change you will discover at the pharmacy counter.

When to bring in a counselor or lawyer

Free side-by-side comparisons are available through the Missouri Serving Health Insurance Program, and the Local Help With Paying for Care page lists how to reach a counselor. A counselor can run the comparison against your parent's full drug list and explain the enrollment window that applies. Enrollment deadlines are set by Medicare and can close, so ask the counselor to confirm which window is open before you sign.

If a plan denies coverage and you want to contest it, the appeal steps are described on medicare.gov. Once a contest turns on a legal question about the plan's contract, the matter belongs with a lawyer, and the Missouri Bar's referral service is the place to start. The Sources page lists the public references used in this guide.