How do I find a Medicare Part D plan that covers nursing...

1 answer | Last updated: Apr 24, 2012
Gwendolyn asked...

How do I find a Medicare Part D plan that covers nursing home drugs?

Expert Answers

Generally, the task of picking the right Medicare Part D prescription drug plan is the same whether someone is in a nursing home or not. That's because paying for the cost of a nursing home does not include prescription medications, which must be paid for separately. So, the job of picking a plan for someone in a nursing home requires all the same steps as for someone else. The only major difference is that nursing home residents have greater freedom to switch plans if they are not satisfied with the plan they have. Most people may only switch plans once a year. But a nursing home resident may switch plans as often as once a month. So, anytime you find a better plan, or the prescribed drugs change, you can switch plans with no penalty.

There are a number of things to consider when choosing a Medicare Part D prescription drug plan. These include:

  • Whether the drugs the patient regularly takes are all included in the plan's list of covered medications, called a "formulary." If a drug isn't in a plan's formulary, the plan won't pay anything toward its cost. Plans change formularies often, so always check a plan's current formulary directly with the insurance company itself.

  • Most drug plans have a tier system in which they pay more for some drugs than for others. If a patient takes a drug that's on a plan's tiered formulary, it's important to see whether it is on a lower-cost or higher-cost tier.

  • Even if two different plans both cover a particular drug, a patient's co-payment share for that drug can vary from one plan to another. So, compare total out-of-pocket costs -- the premium plus all co-payments -- of any plan with those of comparable plans.

  • Once a patient's total drug costs for the year add up to $2,510 (in 2008), she reaches the Part D coverage gap or "donut hole." From then on, until out-of-pocket costs reach $4,050 for the year, a Part D plan isn't required to pay anything. Some plans, however, offer a certain amount of coverage during this gap. Premiums for these plans are higher, but if someone has high yearly drug costs that will go well into the donut hole, a higher premium might be worth the extra coverage.

There are other factors to consider, too, such as whether the plan can override a doctor's prescription and substitute a less expensive drug for the one prescribed, whether a patient needs the plan's prior authorization before it will cover a certain drug, and whether the plan can require a patient to try less expensive drugs before being covered for a higher-cost drug.

For a full explanation of how to choose a Medicare Part D prescription drug plan, see the article on this site Choosing a Medicare Part D Prescription Drug Plan.