Understanding Medicare Part D

Pharmacy technicians who work in a retail pharmacy setting must understand all the ins and outs of working with drug insurance companies, and with the vast amount of health insurance programs available to the public, this can seem like a daunting task to say the least.

The good news is that once you begin working at a pharmacy, you will become very familiar with the handful of insurance companies that cover most of your customers. You can also start learning a bit about some of the programs right now. Two of the most common health insurance programs you’ll work with on a daily basis are Medicaid and Medicare. Let’s take a look at Medicare.

Medicare, as you probably know, provides insurance coverage for people age 65 or older. People younger than 65 can qualify as well if they have Lou Gehrig’s disease, kidney failure, or certain other disabilities.

The part of Medicare that allows its eligible patients the option of adding drug insurance to their health coverage is known as Medicare Part D. Here are a few facts to keep in mind:

  • It is voluntary. If your customer can get drug coverage through a private health insurance company or an employer for a premium that costs less, you could encourage them to do so.
  • It is complex, but the pharmacist and the other technicians you work with who have more experience will be able to help you understand the complexities.
  • Participants are often confused and will have a lot of questions about what is covered. Again, with the help of your co-workers and with some experience under your belt, you’ll be able to handle this.

One other fact to be aware of is that the benefit gives the patient initial coverage up to a certain level—usually $3000—and then there’s a gap known as the “doughnut hole” before coverage kicks in again—at around $5500—where the patient is responsible for 100% of the cost of their medications. Your customers will be very surprised at how much their medications cost when they’re in the doughnut hole, so be prepared to explain this as best you can. 

Medicare Part D, as well as Medicaid, also has regulations that must be followed. For example, under OBRA-90, if a pharmacy doesn’t screen prescriptions and counsel patients, they face potential loss of Medicare participation. 

Just remember to be patient with yourself as you are learning to understand insurance companies and their benefits. Repetition and asking for help are the keys!

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