Prescription Drug Insurance: Medicare Part D for People with Kidney Disease

When you have chronic kidney disease (CKD) and require dialysis, there are many prescribed medicines you have to take. But prescriptions can be costly. In association with Medicare Part A and B, Medicare Part D became part of the Medicare reform signed into law in December 2003. Medicare Part D – formally known as the Medicare Prescription Drug, Improvement and Modernization Act – is a prescription drug insurance that is for people who have Medicare Part A, Part B or both.

Medicare Part D eligibility

People who can receive Medicare Part D are those who have enrolled in Medicare Part A, Part B or both because of:  

  • ESRD – a person of any age with end stage renal disease (ESRD) can apply for Medicare Part D 3 months before to 3 months after he/she is eligible for Medicare.
  • Age – Americans 65 or older can apply for Medicare Part D 3 months before to 3 months after their 65th birthday.
  • Disability – People who are 100% disabled can apply for Medicare Part D 3 months before to 3 months after month 25 when they begin disability.

You are not required to get Medicare Part D if you have creditable coverage with a commercial insurance plan (such as workman’s compensation). Creditable coverage is health insurance that can be used to make up for a preexisting condition exclusion period. Be sure to verify that your prescription coverage is regarded as creditable.

Double-check your commercial insurance plan if you decide to get Medicare Part D. Make sure your commercial coverage does not put your Medicare Part D plan at risk of being terminated. Ask your insurance agent or human resources representative for guidance if you decide to get Part D.

Enrolling in Medicare Part D

If you qualify for Medicare Part D and would like to enroll, there are several ways to go about it. 

  • If you have just become eligible for Medicare Part A, Part B or both you can enroll in a Medicare Part D plan.
  • If you already have Medicare Part A, Part B or both and have just lost creditable coverage through a commercial insurance plan, you can enroll in Part D based on that qualifying event.
  • If you did not enroll in Medicare Part D when you first became eligible for Part A, Part B or both, there is an Annual Enrollment Period (AEP) for Part D from October 15th through December 7th of each year. (Penalties may apply if you wait to enroll at this time and do not have creditable coverage through a commercial insurance plan.)
  • There may be other circumstances that may allow you to enroll or not enroll in a Part D plan (You may not need to enroll if you do not need dialysis.). These are called Special Enrollment Periods or (SEPS). You can find more information about Special Enrollment Periods at www.medicare.gov. 

Medicare Part D prescription drug coverage is accessible through Medicare-approved private insurers. There are two plans you can choose from: 

  • Medicare Part D plans that add coverage to Original Medicare
  • Medicare Part D plans that are part of Medicare Advantage Plans (HMO or PPO). Many people with end stage renal disease can receive this medication coverage if they already belong to a Medicare Advantage Plan.

Cost of Medicare Part D

Here is a look at how much Medicare Part D may cost people on dialysis: 

  • Premiums: This is the monthly cost you pay to join a Medicare prescription drug plan. The premium cost usually depends on the types of prescription drugs you need for your end stage renal disease, along with which plan you choose. Each plan is different, so premiums can vary.
  • Deductible: This is the amount you pay for your prescriptions before your plan starts to share the costs. Again, each plan is different, so deductibles vary. Some plans may not have any deductible.
  • Co-payment/co-insurance: This is the amount you pay for your prescriptions after you have paid the deductible. In some plans, you pay the same co-payment (a set amount) or co-insurance (a percentage of the cost) for any prescription. In other plans, there might be different levels, or “tiers,” with different costs. (For example, you might have to pay less for generic kidney medications than brand names. Or, some brand names might have a lower co-payment than other brand names.) Also, in some plans your share of the cost can increase when your prescription drug costs reach a certain limit.

Extra Help with your Medicare Part D costs

If you have a low income or minimal resources to pay for Medicare Part D prescription drug plan, you can apply for help. “Extra Help” is a program through the Social Security Administration to help people reduce out-of-pocket expenses for medication when they have Medicare Part D. Here are some other ways you can qualify for Extra Help. 

  • If you have full benefits through a state Medicaid program, you may automatically qualify for Extra Help. You can receive help from Medicaid by paying your Medicare Part B premiums (Medicare Savings Program), or you get Social Security benefits without Medicaid.
  • If you move into a nursing facility or long-term care hospital, you may automatically qualify for Extra Help.

If you automatically qualify for Extra Help, Medicare will enroll you in a Medicare Part D plan and you will be sent a yellow or green letter letting you know when your coverage begins. You may change plans at any time if you are part of this Extra Help program. 

If you believe you have been overlooked and do qualify for Extra Help, you can apply online at www.socialsecurity.gov or call 1-800-772-1213. You can also ask your social worker at the dialysis center to help you with any questions about Extra Help.

Coverage gap or “donut hole” insurance with Medicare Part D

As someone with end stage renal disease, you need to take prescription drugs that may be costly. If so, you will enter a coverage gap, also known as a “donut hole”, in your Medicare Part D coverage. This is where you will be responsible for 100% of the cost of your medicines for a period of time.

This “gap” in coverage generally begins at $2,830 in total drug costs (the amount that has been paid by you and the insurance company for prescriptions up to this point) and lasts until you spend $4,550 out-of-pocket (this amount includes your initial deductible, initial co-insurance/co-pay amounts and the full amount that you paid through the coverage gap.). Once you have spent the out-of-pocket maximum, your Medicare Part D plan will become “catastrophic coverage” and will pay for your drugs at a higher rate with you being responsible for minimal co-pay or co-insurance from that point until the end of the calendar year.

Medicare Part D definitions

Here are some terms you may hear when you start Medicare Part D. This may help you understand what Medicare Part D entails. 

  • Formulary – The list of medications a plan will cover. If a medication is not on “formulary,” you do not get credit for paying cash for that medication drug in the coverage gap.
  • Prior authorization – Also known as prior approval, it is when a prescription insurance plan needs to authorize coverage for a prescription by the doctor. The doctor may have to contact the insurers to see if the medication the doctor prescribes is covered by the plan.
  • Step therapy – A type of prior authorization that requires the patient to try a less expensive drug first. If that drug does not work, then you can move up a “step” to a more expensive drug.

Talk to your social worker about Medicare Part D

Your social worker can help you with questions you may have about Medicare Part D. Social workers at the dialysis center are trained to be experts in answering your insurance questions. Whether you want to enroll for this coverage, need help filling out paperwork or if you have any issues with the insurance plan, the social worker is available to assist you.

Summary

When you have end stage renal disease, you will likely need many prescribed medications to help treat kidney disease. Medicare Part D is a prescription drug insurance that you may be eligible for if you already have Medicare Part A, Part B or both. Talk with your social worker about applying for Medicare Part D.

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