Medicare Prescription Drug Plans (Part D)

You are here:

Medicare Part D provides coverage for prescription medications. Prescriptions are not covered under Original Medicare Parts A and B, so most people purchase a Part D plan to avoid paying the full cost of expensive medicine. Most Medicare Advantage, or Part C, plans already include prescription drug benefits. If yours does not, you can get prescription drug coverage by purchasing a Part D plan.

Medicare Part D Prescription Drug Plans

Part D Medicare is a prescription drug policy that covers most of the medications your doctor prescribes for you. Part D does not cover over-the-counter medicines. Plans also don’t usually cover drugs for such things as cosmetic issues, weight loss or sexual dysfunction. Each Part D plan has a list of covered drugs, known as a “formulary.” The formulary is typically broken down into groups, or tiers, of drugs, based on their cost. Drugs in a lower tier will usually cost you less than those in a higher tier.

Medicare Part D Coverage

  • Deductible – Amount the enrolled pays prior to coverage kicking in. 
  • Initial Coverage – Your plans pays 75% of your prescription drug costs and the enrollee pays 25% up to the plan limit
  • Coverage Gap – This is also known as the Medicare donut holeThe plan will pay 49% for generic drugs and 10% for brand name drugs. For brand name drugs, the manufacturer discounts there costs by 50%, this discount is counted as an enrollee out of pocket cost expenditure. The enrollee pays 51% of the cost for generic drugs and 40% of the cost of brand name drugs. 
  • Catastrophic Coverage – Once you’ve reached the annual out of pocket threshold, the plan pays for 95% of your drug costs. 

Medicare Part D Drug Plan Cost

You’ll pay a premium for your Medicare Part D prescription drug coverage, but the premium amount will vary depending on your plan. In addition, if your income is above a certain amount, you may have to pay a Part D income-related monthly adjustment amount that could range from about $13 to $76, depending on your income.

Some drug plans also have a deductible – an amount you must pay out of pocket each year before your plan begins paying benefits. Deductibles vary from one plan to another, but they cannot be higher than a certain amount. For example, for 2017, no plan can have a deductible greater than $400.

When you pick up a prescription at your pharmacy, several things determine what you will pay:

  • Whether the pharmacy is “in network” and accepts your Part D plan
  • Whether you have met your deductible.
  • Your plan’s coinsurance or copay amounts. Copays are a flat fee that you pay for a particular tier of drugs — $10 per prescription, for example. Coinsurance means you pay a percentage of the cost of your medication, such as 20 percent.
  • The type of medication. Some drugs cost much more than others.
  • Whether you are in the coverage gap, or “donut hole.” Most Part D plans cover your medications until you and the plan have spent a certain amount. You are then in the “donut hole” and will pay a percentage of the total cost of your medication until you reach another threshold. After that, you pay only a small fraction of your drug costs for the rest of the year.

When comparing Part D plans, it’s a good idea to research deductibles, copays and costs for the medications you currently take.

Medicare Prescription Drug Plans Extra Help Program

Another helpful piece of information is the Extra Help program available through Medicare. Extra Help helps those with certain limitations on income and resources to pay for the cost of prescription drugs. The level of assistance you may receive depends on your individual financial situation. If you already qualify for Medicaid in your state, then you automatically qualify for Extra Help once you become eligible for Medicare. Extra Help or Low-Income Subsidy (LIS) also means that you can change your plan as often as necessary, unlike most people who must wait until the next Annual Election Period. 
No matter which route you choose, it’s important to know as much information as possible. There’s another thing to consider when asking What is Medicare Part D? Insurance companies make changes frequently, especially to their formulary. A formulary is a comprehensive list of the prescriptions that are covered under standalone Medicare Part D Prescription Drug plans. This list is modified, as needed, based on prices and information from pharmaceutical companies and regulations set by the Centers for Medicare and Medicaid Services. It’s important to make sure that your particular prescriptions are included in your Medicare drug plans formulary before making any commitment.

When Can I Purchase a Standalone Medicare Prescription Drug Plan

If you are turning 65 and eligible for Medicare for the first time, you have a seven-month window to sign up for Part D. Your window opens three months before the month you turn 65, includes your birthday month, and closes three months after you turn 65.

There’s also an Open Enrollment Period from October 15th to December 7th each year. During this time, you can add a Part D plan, switch from one Part D plan to another, or drop Part D coverage altogether. You may have additional enrollment opportunities if you enrolled in Part B during annual open enrollment, are switching from Medicare Advantage to Original Medicare, or qualify for a special enrollment period based on life events such as moving or losing your employer insurance coverage.

However, if you are eligible for Medicare and go without prescription coverage, you may pay a penalty when you do enroll in Part D. This monthly penalty, based on the amount of time you were without coverage, continues for the entire time you have a Medicare drug policy.

Medicare Part D Penalty 

There’s other important aspects to consider as well. You should be aware of the potential Part D penalty. If you don’t have credible prescription drug coverage once you qualify for Original Medicare, you become subject to a penalty. Medicare determines the amount owed by multiplying 1% of the national base beneficiary premium times the number of months you went without Part D coverage. This penalty is deducted from your Social Security benefits for life, regardless of whether or not you choose a plan immediately afterwards.

At MedicareFAQ, we want to simplify the process of applying for Medicare coverage. Contact us for a free quote and we’ll search all the top insurance companies in your area to get you the best rates on the policy that’s right for you.

Sign Up for Medicare Part D Online

For more information on any traditional Medicare or Medicare Supplement plans, please read our FAQ section. We provide tons of useful information to help you become educated on all the plan options you have. You can also check out our informational videos where our agents answer the top questions Medicare recipients have.
At MedicareFAQ, we want to simplify the process of applying for Medicare coverage. Contact us for a free quote and we’ll search all the top insurance companies in your area to get you the best rates on the policy that’s right for you. Our compare rates form will find the carriers in your area and put the rates side by side to compare which plan is best for you and your personal budget. To get started, click here to sign up for Medicare Part D Online!