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Medicare Part D
Medicare Part D is the prescription drug coverage administered by Medicare. It gives beneficiaries the opportunity to purchase retail prescriptions at an affordable, discounted rate, as opposed to paying the full price out-of-pocket, and being at risk of prescription price increases.
Medicare prescription drug coverage can be provided by a stand-alone Medicare Part D plan (only prescription coverage), or a Medicare Advantage plan that includes prescription coverage. To enroll in to Part D, you do not go through Medicare, but to a private insurance company in your state that is approved by Medicare.
You must be enrolled in Parts A and B in order to enroll in a plan offering prescription benefits.
Part D Costs
Part D coverage is designed with a formulary, tiers, co-payments and co-insurance. All plans will offer benefits for both generic and brand name drugs.
Every provider of Part D benefits has the freedom to select their formulary as well as establish their co-payments and tiers.
It is vital that you use one of the tools available to search your drug options or contact us to help you in evaluating your plan options.
Medicare Part D, when purchased with a Medigap plan, has its own separate premium. If a beneficiary purchased a Medicare Advantage program, their Part D benefits would be included in the plan and, therefore, the premium would reflect this combination of benefits.
Medicare Part D Income Related Monthly Adjustment Amount (IRMAA) – Find out if you are subject to additional Part D premiums. Read more about how your income can affect your Medicare Prescription Drug Coverage premiums on our Medicare Costs page.
How Can I Get Part D Coverage?
There are two ways to secure coverage for your prescription drugs:
Through a Stand-Alone Prescription Drug Plan:
✓ If you purchase a Medicare Supplement (A, F, G, or N), you will need to purchase a stand-alone Part D plan (PDP).
✓ Certain Medicare Advantage (MA) plans and some Private Fee For Service (PFFS) plans exclude prescription coverage. In these cases, you would be eligible to enroll in a stand-alone Medicare Prescription Drug Plan.
Through a Medicare Advantage Prescription Drug Plan:
✓ You purchase a Medicare Advantage (MAPD) Part C plan with built-in Part D coverage. Therefore, your Part D coverage is already included in your single plan.
Part D Late Enrollment Penalty
If you do not enroll in Part D coverage when you are eligible, you may incur a late enrollment penalty equal to 1% of the “national base beneficiary premium,” which is $33.06 in 2021. The amount of penalty incurred would be in addition to your Part D premiums.
Medicare Part D Terms You Should Know
Tier of Charges
Different levels of copays, ranging from least expensive (usually generic drugs), through medium cost (usually “preferred” brand-name drugs) and higher cost (“non-preferred” brand names) to highest cost (rare and very expensive drugs). Charges for each tier vary among plans.
Your copay or coinsurance depends on which tier your drug is placed in by your plan.
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
Late Enrollment Penalty
The extra amount you pay in premiums if you do not sign up for Medicare drug coverage when you first become eligible, unless you already have creditable coverage from elsewhere.
A dollar amount, set each year by law, that releases you from the coverage gap and qualifies you for low-cost catastrophic coverage, if your drug costs reach that level in any one year. Any payments you’ve made for your drugs out of pocket since the beginning of the year count toward the limit, and are known as true out-of-pocket costs.
True Out-of-Pocket Costs (TrOOP)
The payments that count toward the out-of-pocket limit that gets you out of the coverage gap and triggers catastrophic coverage, if your drug costs run that high in a year. These payments include your deductible, copays in the initial coverage period and anything you’ve paid for your drugs in the gap — but not your premiums — since the beginning of the year. It also includes discounts on brand-name drugs that are provided by the manufacturers in the coverage gap.
A plan’s ability to restrict the maximum amount of a drug to be prescribed at one time because of safety or cost concerns. For example, if your doctor prescribed a 60-day quantity for a medication, your plan can intervene and provide only a 30-day supply based on their policies regarding quantity limits.
A type of prior authorization. It is a feature of Part D plans where the plan requires you to accept a less expensive drug before a more expensive one. This can occur when a brand name drug is prescribed, but a cheaper generic brand may be available. Therefore, the plan would direct you to accept the cheaper drug, but if your condition fails to improve, they then would provide you the more expensive drug.
If you want to avoid step therapy, your physician must provide proof to the plan of your failed attempts to use a lower-cost drug(s).
When the plan must approve a drug before it can be prescribed to you. This can often happen under two scenarios. First, when a drug is considered very powerful or could have safety concerns if you are on it for an extended period of time. Second, if a drug can be covered under Part D, Part B or Part A. If the drug is approved under Part D, the plan will cover the drug. However, if denied under Part D, you should ask your doctor to file a claim under either Medicare Part A or Part B.
Medicare Part D Plan Year Stages
The amount you pay each year before coverage kicks in.
The amount your plan pays after the deductible (if any) has been met and prior to the coverage gap.
Coverage Gap – aka Donut Hole
The gap between initial and catastrophic coverage, a period in which you used to be required to pay 100 percent of your prescription costs if you have no additional drug coverage. However, from 2011 onward a provision of the 2010 Affordable Care Act began to narrow the coverage gap. In 2016 you receive discounts of 55 percent on your brand-name drugs in the gap and a 42 percent discount for generic drugs, so that you pay 45 percent for brands and 58 percent for generics. (In 2017, you pay 40 percent and 51 percent respectively.) Over time these discounts will grow larger until, by 2020 you’ll pay no more than 25 percent of the cost of any drugs in the gap. You fall into the gap if and when your total drug costs rise above a certain amount in the year.
The level of coverage when Medicare covers almost all your costs after you’ve passed through the coverage gap and spent a certain amount out-of-pocket in a year.