Medicare Part D: Drug Coverage

        Medicare Advantage Plan come with Drug Plan with $0 premium (MAPD) plans

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           YOU CAN ONLY BUY DRUG COVERAGE FROM PRIVATE INSURANCE

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            Which plan is best for me?

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You need to first understand the terminology of the plan

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Maximum out-of-pocket (MOOP) - We feel this is most important 

The maximum out-of-pocket is the most that you will be required to pay each year for deductibles, copayments and coinsurance on covered medical expenses.

It does not include the amount you pay for drug prescriptions and monthly plan premiums

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What is Deductible: 

A deductible is a set dollar amount you may be required to pay toward covered medical expenses within a single year before your health insurance company will begin paying for your care.

Most Medicare Advantage Plans have $0 medical deductible

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What is Copay: 

A copay is a set dollar amount that the policyholder agrees to pay for various kinds of care and treatment—like doctor visits, specialist visits, preventative care, and prescriptions. For instance, you may have a copay of $15 dollars when you go visit your primary care provider. Your insurance may cover the rest of the cost if you’ve reached your medical deductible

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What is Coinsurance: 

Coinsurance is the percentage % a policyholder pays for health services after the deductible has been met. For example, if the insurance covers 70%, you pay 30% coinsurance. You pay your coinsurance till you reach your MOOP

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What is Medicare Drug Part D deductible: 

Part D has separate deductible than Medical Medicare Part A and Part B.

For 2026 the maximum deductible is $615 (usually for tier 3,4,5)

For 2026 the maximum out if pocket is $2100

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Example to make you understand the terms

Plan has the following

Maximum Medical out of pocket (MOOP) - $7,200

Primary Doctor Copay - $10

Specialist Copay - $15

Medical Deductible - $1,000

Coinsurance - 20%

Prescription Deductible - $615

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Routine Checkup: 

You go to the doctor for a cold. You pay your $10 copay at the desk.

Your insurance covers the rest of the visit's cost.

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Medical Test: 

The doctor orders an MRI that costs $800.

Since you haven't hit your $1,000 medical deductible yet, you pay the full $800.

Your medical deductible balance is now $200.

Emergency Visit: 

Later, you have a minor injury that costs $500.

You pay the first $200 to reach your $1,000 deductible limit.

For the remaining $300 of that emergency bill will be coinsurance since you have not reached your $7,200 MOOP

You pay 20% x $300 = $60, insurance will pay 80%x300=$240

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Surgery: 

Later, you have a surgery that costs $10,000.

You have paid your deductible of $1,000 but you have not reached your MOOP yet

You pay 20% x $10,000 = $2,000, insurance will pay 80%x10,000=$8,000

You have paid $1,000 deductible plus $2,000 for surgery which is $3,000 but less than $7,200 MOOP

Hospital:

Later, you have hospital stay that costs $50,000.

You have paid $1,000 deductible plus $2,000 for surgery which is $3,000 but less than $7,200 MOOP

You pay 20% x $50,000 = 10,000, insurance will pay 80%x50,000=$40,000

BUT you will only pay $7,200 - $1,0000 - $2,000 = $4,200  not the $10,000 since you have reached your $7,200 MOOP

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FOR THE REST OF YEAR EVEN IF YOUR HOSPITAL BILL IS $1,000,000 YOU PAY NOTHING

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With Medicare Advantage Plan once you pay your yearly maximum out of Pocket (MOOP) than you pay nothing

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Example for drug coverage Part D 

Prescription Deductible - $615

Most MAPD plans have 5 tiers (read section Part D)

Most MAPD plans have the deductible for Tier 3,4,5

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You need some generic medication - usually it in tier 1, cost $0 with no deductible

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You need cancer drug - it is in tier 5, Cost is $10,000 

You will pay the $615 deductible first.

Than you will pay the coinsurance 20% x$10,000= $2,000

There is Maximum limit for out of pocket on drugs - $2,100

You will pay total $2,100 not $615 +$2,000 = $2,615 over the drug MOOP 

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FOR THE REST OF YEAR EVEN IF YOUR DRUGS COST IS $1,000,000 YOU PAY NOTHING

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Note: You need to read your plan summary of benefits to get the details

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What do I need to look for in the plan ?

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You should consider your own medical situation, like your Primary Care Physician (PCP), Specialist and the prescriptions you take.

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Check which Hospital networks your doctors are in and if your prescriptions are covered by that plan’s formulary and in which copayment tier they fall.

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Check what MOOP, copays, coinsurance, benefits you want from the plan

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We have national carriers

Aetna, Devoted, Cigna Health Spring, Humana, United Healthcare, WellCare Centene, Wellpoint Anthem 

Your PCP or hospital network will be in one or most of national carriers

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A Primary Care Physician (PCP) may or may not be in a specific hospital's network, as they can be independent or affiliated with various health systems. You need to ask the doctor directly if they are in-network for your specific plan, or verify with the hospital's patient services

A PCP must contract with your specific insurance plan to be considered "in-network," regardless of their hospital affiliation.

Always confirm network status with your insurer to avoid higher, out-of-network costs

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Do I choose HMO or PPO

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When the time finally comes to select a health insurance company and plan, be sure to put your and your family’s specific medical needs under the microscope. You’ll want to reflect on how much and what type of treatment you’ve received in past years. Though it’s impossible to predict every medical expense, being aware of certain trends can help you make a more informed decision.

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HMO health insurance plan consists of limited a network of doctors and hospitals from which you can receive treatment

You are simply focused on keeping your medical expenses at a minimum, 

Your primary care physician who will refer you to specialists when you need additional treatment

Most people have HMO 

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PPO plans offer customers a more extensive network of doctors and hospitals to choose from.

You can afford higher premiums and already know that you’ll need to visit specialists frequently because of existing health conditions 

If you’re constantly on the go, as you’ll have a better shot of receiving care that’s fully covered by your provider when you’re on the road.

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      Sample list of Houston Hospitals & Physician Groups​​​​​​​​​

Major hospital networks in Houston accepting Medicare include Houston Methodist, Memorial Hermann, HCA Houston Healthcare, CHI St. Luke's Health, and Harris Health System. These systems, along with many specialized centers, provide coverage for Medicare beneficiaries. Houston Methodist, for example, is in-network with many Medicare Advantage plans

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Non-covered Charges: Costs for services that your insurance plan doesn’t cover. Examples can include certain drugs, procedures, or alternative therapies.

Excess Charges: Additional charges from a provider who doesn’t accept your insurance plan’s payment as full reimbursement. Common in plans without out-of-network benefits or in Medicare Part B.

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