- Plan Name: This is the official Medicare Part D prescription drug plan or Medicare Advantage name from the
Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different
Plan ID in each state (or CMS Region). The plan name is followed by the plan type
(PDP,
HMO,
HMO-POS,
PPO,
PFFS, etc.)
- Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
- Deductible: If your Part D plan has an
initial deductible,
you are 100% responsible for your drug costs until your expenses exceed this value
and you begin your
Initial Coverage Phase.
- Many Medicare Part D plans use the standard $545 deductible as provided in the CMS Standard plan design.
- Some Part D plan providers offer an initial deductible lower than the Standard deductible.
- Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
- *Some Part D plans exclude some drug tiers from the deductible. If the deductible field above is followed by * (example: $545*), then this drug tier is excluded from the deductible.
- Gap Coverage: In the CMS Standard Plan,
the beneficiary, or others on their behalf (e.g. the brand-name drug manufacturer discount), pay(s)
up to $6,334 in drug costs,
depending on your mix of generics and brand-name drugs.
The Healthcare Reform provides that for plan year 2024,
all formulary drugs will have at least a 75% discount in
the coverage gap (Donut Hole).
The Gap Coverage Types discussed in this section are
supplemental coverage your plan pays in addition to the Healthcare Reform mandated discounts. In our chart, you will see one of the following:
- No Gap Coverage: You receive the 75% Donut Hole Discount and pay up to $6,334 depending on your mix of generics and brand-name drugs, before exiting into Catastrophic Coverage. Read more...
- Yes: This plan offers some supplemental gap coverage in addition to the 75% Donut Hole Discount. See plan details for a description of the gap coverage. The description may read similar to: Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
- Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
- Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
- Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the
Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $5,030) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $5,030) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires
drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.
- Plan’s Avg. Retail Drug Price: This is the Medicare Part D prescription drug plan’s average negotiated retail drug price. This price is calculated for each plan by averaging the negotiated retail price for a particular drug across all pharmacies in the plan’s service area. For example, the negotiated retail drug price for Quetiapine Fumarate 25MG Tables on the AARP MedicareRx Saver Plus plan in Florida (S5921-356) is determined by averaging all of the AARP MedicareRx Saver Plus plan’s negotiated retail drug prices for a Florida pharmacies.
(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2024)
Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.