|Answer: In general, Medicare Part D prescription drug plans provide insurance coverage for your out-patient prescription drugs - so Part D plans work just like other types of insurance: (1) you usually pay a monthly premium for coverage, (2) you may pay an initial deductible before your plan coverage begins, and (3) you and your insurance then each share a portion of the coverage costs (for example, your plan pays 75% of retail drug prices and you pay the 25% balance).|
Your Medicare Part D prescription drug coverage can be provided by:
Quick Review: Medicare A, B, C, and D
- a "stand-alone" Medicare Part D prescription drug plan (PDP), only providing prescription coverage or
- a Medicare Advantage plan that includes prescription coverage (MAPD). A Medicare Advantage MAPD includes your Medicare Part D prescription drug coverage - plus includes Medicare Part A coverage (for in-patient and hospital care) - plus Medicare Part B coverage (for out-patient and physician care) - and often other benefits such as basic dental coverage, optical coverage, hearing aid coverage, and fitness coverage - all for one monthly premium. Medicare Advantage plans are also called Medicare Part C.
- Plus, you can also receive prescription drug coverage from other sources such as your Union, Employer Health Plan, TRICARE for Life, or the Veterans Affairs (VA).
Are all prescription drugs covered by Medicare Part D prescription drug plans?
- Medicare Part A - Medicare Part A provides hospital or inpatient coverage. You may pay a deductible, co-payment, or co-insurance (percentage of cost) for care under Medicare Part A. Most people receive Part A without paying a monthly premium because they (or their spouse) have been working (and paying Medicare taxes) for more than 10 years. If you have Medicare Part A, it will be printed on your red, white, and blue Medicare card. Medicare Part A may cover prescription medications during inpatient care.
- Medicare Part B - Medicare Part B provides coverage of doctor visits and outpatient care. You may pay a deductible, co-payment, or co-insurance (percentage of cost) for care under Medicare Part B. You will pay a monthly premium for Medicare Part B coverage (unless you receive some form of financial assistance such as Medicaid). Medicare Part B may pay for some medications that are administered in a doctor's office or by a healthcare provider - but, usually not for self-administered prescriptions. If you have Medicare Part B, it will be printed on your red, white, and blue Medicare card. Medicare Part B should cover vaccinations such as Flu shots.
Medicare Part C - Medicare Advantage plans are also considered Medicare Part C plans and provide Medicare Part A and Medicare Part B coverage from private insurance companies. Medicare Advantage plans can come with prescription drug coverage (MAPD) or without prescription drug coverage (MA). Important: If you join a Medicare Advantage MA plan, you may not be allowed to also join a separate Medicare Part D plan. Monthly premiums for Medicare Advantage plan may actually be less than $0 (they pay you a dividend or rebate on your Medicare Part B premium) or $0 or range to $150+ per month. Medicare Advantage plans are not the same as Medicare Supplements.
- Medicare Part D - Medicare Part D plans provide prescription drug coverage and may be stand-alone Medicare Part D prescription drug plans (PDP) or Medicare Advantage plans that include prescription drug coverage (MAPD). Medicare Part D is provided by private insurance companies. Monthly premiums for stand-alone Medicare Part D plans (PDPs) may range from $15+ to around $180 per month.
No. Medicare Part D plans are not required to cover all other prescription
drugs - but instead are only required to cover a fixed number of drugs in different therapeutic drug classes. The medications covered by a Medicare Part D plan are organized in a formulary or drug list and this list must cover at least two drugs in each drug category and all drugs (with a few exceptions) in the six therapeutic categories: antidepressants, antispychotics, anticonvulsants (drugs to preventseizures), antiretrovirals (drugs to treat HIV/AIDS), immunosuppressants, and antineoplastics(cancer drugs). In general, a Medicare Part D plan may include several thousand medications in different forms (for instance, 10mg, 20mg, and 40mg Advair Diskus MIS 250/50). Medicare Part D plans also cover vaccinations not covered by Medicare Part B. Each year, a Medicare drug plan can change the plan's formulary. However, Medicare
Part D Medicare Part D plans are regulated by the Centers for Medicare and Medicaid Services (CMS) and CMS must approve a Medicare plan's formulary or drug list every year.
Please note: Some prescription drugs are excluded from the Medicare Part D program by law (such as drugs for weight loss, erectile dysfunction, cosmetic purposes, or hair growth) - however, it is possible that you plan may provide supplemental coverage of these non-Part D drugs as "Bonus Drugs".
Tip: You can see all drugs covered by a particular Medicare plan by using our Q1Medicare Formulary Browser, you can always change the name of the Medicare Part D plan and state to browse other formularies. You can also browse all Medicare Part D plans in a certain area that cover a specific medication - and at what cost using our Q1Medicare Drug Finder tool (found at Q1Rx.com).
A note on employer prescription drug coverage
If you are receiving prescription drug coverage from your employer, the key is to ensure that any Employer Health Plan provides "creditable" prescription drug coverage so that you avoid any Late-Enrollment penalties.
Important: If you have an employer health plan that includes prescription drug coverage - and then enroll in a Medicare Part D plan, you risk losing all of your employer health plan coverage, not just drug coverage. You can click here to read more in our Frequently Asked Questions about checking with your employer health plan administrator before enrolling in a Medicare prescription drug plan.
A note on Veterans Affairs (VA) prescription coverage
If you have VA coverage (that is, prescription drug coverage as part of Veterans Affairs benefits), then you may not need Medicare Part D coverage. However, if you find that the VA does not cover all of your medication needs, you can also enroll in a Medicare Part D program. The two programs actually work together, allowing coordinated coverage - first under the VA and secondly under your Medicare Part D plan. Your VA coverage is also considered "creditable coverage" and should you decide to enroll into such a Medicare Part D plan after the close of your initial enrollment period, there will be no penalty for late enrollment. You can click here to read more in our VA section of Frequently Asked Questions.
A note on the Late-Enrollment Penalty
Late-Enrollment Penalties are assessed when you eligible for Medicare Part D coverage, but are without some form of creditable drug coverage for more than 63 days. You can click here to read more in our late-enrollment premium penalty section of Frequently Asked Questions. Late-enrollment penalties are permanent and can change (increase) year-to-year.
How your Medicare prescription drug plan works: Your Medicare Part D plan coverage is divided into four parts or phases.
(1) The Initial Deductible phase is where you pay 100% of your retail drug costs until you reach your deductible amount (for instance, the 2018 standard initial deductible is $405). Many people will enroll in a Medicare prescription drug plan with a $0 deductible and effectively skip-over this first "deductible" phase. Also, some Medicare Part D plans will exclude less-expensive drugs (such as Tier 1 generics) from the plan's initial deductible, so it is possible that you may have coverage for some low-costing drugs even though you have not met your plan's initial deductible.
(2) The Initial Coverage Phase is where you and your Medicare Part D plan will share in the cost of your medication purchases based on your plan's cost-sharing (such as a $30 co-payment or 25% co-insurance). When the retail value of your drug purchases exceeds your Initial Coverage Limit (ICL or Donut Hole entry point), you will leave your Initial Coverage Phase and enter the Coverage Gap or Donut Hole.
Please note that the Initial Coverage Limit is not measured by what you have spent on medications. Instead, the ICL is the total retail value of your prescription drug purchases. So the ICL is the amount that you pay for your prescriptions plus what your Medicare Part D plan is paying. As reference, the ICL in 2015 was $2,960, the ICL was $3,310 in 2016, and the ICL is $3,700 in 2017 (the ICL in 2018 will be $3,750).
For example, if you fill a $100 prescription in 2018 and you pay a $30 co-pay (the Medicare Part D plan pays the other $70), the total $100 retail cost is credited toward your 2018 Initial Coverage Limit of $3,750. In this case, after the $100 drug purchase, you have $3,650 remaining in drug purchases before entering the 2018 Donut Hole or Coverage Gap.
(3) The Coverage Gap or Donut Hole is the drug plan phase you enter once you exceed the Initial Coverage Limit and where (before 2013) you were originally responsible for 100% of your drug costs (so this was like a second deductible phase) - but now you receive a Donut Hole Discount on your generic and brand-name drug purchases while in the Coverage Gap
For instance, in 2018, you will received a 65% discount on brand-name drugs and a 56% discount on generic drugs (you will pay 35% of your plan's negotiated retail cost for brand-name prescriptions and 44% of the retail cost for generics). As a comparison, in 2017, you received a 60% discount on brand-name drugs and a 49% discount on generic drugs (you paid 40% of your plan's negotiated retail cost for brand-name prescriptions and 51% of the retail cost for generics).
The Donut Hole will be reduced to a fixed 25% co-insurance cost-sharing structure for both generics and brand-name drugs by 2020. You can read more about the current Donut Hole Discount here: https://q1medicare.com/q1group/MedicareAdvantagePartDQA/faq/What-kind-of-discount-can-we-expect-in-the-Doughnut-Hole-/470/129.html.
You can read more about the current 2017 Donut Hole here: "https://q1medicare.com/q1group/MedicareAdvantagePartD/Blog/How-much-money-could-I-possibly-save-with-the-2017-Donut-Hole-Discount-/584/22.html"
(4) The Catastrophic Coverage Phase is the last phase of your Medicare Part D plan coverage and you enter once your total out-of-pocket drug costs (or TrOOP) exceed a certain point (over $4,700 in 2015 or over $4,850 in 2016 or over $4,950 in 2017 or over $5,000 in 2018). During this phase you will exit the Donut Hole or Coverage Gap and will receive your medications at a low-fixed price, paying a maximum of 5% of the retail price for the remainder of the year.
TrOOP is what you have spent out of pocket for medications, but does not include your monthly premiums. Also, although you receive a 65% discount on brand drugs in the 2018 Donut Hole (you pay 35% of retail), you will actually get 85% of the retail price credited toward your TrOOP.
So if you purchase a brand name drug in the Donut Hole with a retail cost of $100, you pay $35 (you get 65% discount in 2018) and you get $85 credited toward your TrOOP or Donut Hole exit point. (Please note: this is a good thing because you will need to spend less to get out of the Donut Hole phase and enter the lower-costing Catastrophic Coverage phase.)
When can you enroll into a Medicare Part D plan?
Your Initial Enrollment Period: If you are new to Medicare, you have an Initial Enrollment Period (IEP) that is a seven (7) month window beginning three (3) months before your month of eligibility, plus the month of eligibility, and ends three (3) months after your month of eligibility.
If you enroll in the three months prior to your month of Medicare eligibility, your effective date (when your plan coverage begins) is the 1st day of your month of Medicare eligibility.
If you enroll into a Medicare Part D plan during your month of eligibility (such as when you turn 65) or during the three months following the month of Medicare eligibility, your Medicare Part D plan will be effective on the 1st day of the month following receipt of your plan enrollment.
The annual Open Enrollment Period: If you are already eligible for Medicare, you can change Medicare plans during the annual Open Enrollment Period (AEP). The annual Open Enrollment Period starts each year on October 15th and continues through December 7th with your Medicare Part D plan becoming effective on January 1st of the new plan year.
Special Enrollment Periods: If you are outside of your IEP or AEP, then you will need to use a Special Enrollment Period (SEP) to change Medicare Part D or Medicare Advantage plans. An SEP may be granted when you move outside of your plan's Service Area (move to another state) or move into an assisted living facility or when you qualify for Extra Help.
If you are entitled to an SEP, your Medicare Part D plan will become effective on 1st day of the month following the receipt of your enrollment. See our Special Enrollment Period FAQ for more details and examples of SEPs.
What you pay: (1) Your monthly premium.
If you join a Medicare Part D prescription drug plan, you will pay a monthly premium ranging from only a few dollars up to over 100 dollars. If you join a Medicare Advantage plan, you may have a $0 premium - and, depending on the MAPD, may actually get a portion of your Medicare Part B premium rebated back to you (a "dividend" plan). Your monthly premiums will vary depending on the benefits of your selected Medicare Part D plan or Medicare Advantage plan and your resident state. You can see a list of all Medicare Part D plans in your state using our Medicare Part D Plan Finder (PDP-Finder.com/FL). You can see a list of all Medicare Advantage plan in your ZIP Code region using our Medicare Advantage Plan Finder (MA-Finder.com/90210). You can also learn about the Medicare Part D plan premiums in your area by calling Medicare at 1-800-633-4227.
What you pay: (2) Your prescription drug costs.
As mentioned, your coverage costs can change depending on the phases of your Medicare Part D plan. In the Initial Deductible, you will pay 100% of your retail drug costs. In the Initial Coverage phase, you will share the cost with your drug plan (for example, you pay 25% of retail or a fixed co-pay of $30 for brand-name drugs). In the Coverage Gap or Donut Hole, you will receive a discount on the retail price depending on whether you are purchasing generic drugs or brand-name drugs. In the Catastrophic Coverage phase, you will pay around 5% of the retail price for your medications.
What you pay: (3) Your healthcare costs - with a Medicare Advantage plan.
If you join a Medicare Advantage plan that includes drug coverage (MAPD), you will receive coverage as mentioned above and you will also receive coverage for your Medicare Part A (in-patient costs) and Medicare Part B (out-patient costs), plus you may also receive additional dental, vision, health club coverage, depending on your plan. The Medicare Advantage plan coverage should be at least as good as the Original Medicare coverage provided by the government. However, Medicare Advantage plans will have a maximum out-of-pocket spending limit (MOOP), that will be around $6,700 or less - meaning that your healthcare costs will not exceed this amount for a calendar year.
Financial assistance with Medicare Part D prescription drug costs - and Medicare Part A or Medicare Part B costs.
The Medicare Part D Extra Help program is available to help people with limited financial resources pay for their monthly premiums and drug costs. The Extra Help or Low-Income Subsidy (LIS) program is based on a Medicare beneficiary’s income and assets (or financial resources). For more information, please contact your state Medicaid office.
Medicare Savings Programs are also available and, depending on your finances, may help pay Medicare Part A and/or Medicare Part B premiums, and maybe some Medicare Part B costs.
Important: Medicare Part D and Medicare Advantage plans change each year.
Please note that Medicare Part D and Medicare Advantage plans change each year. For example, if you are eligible for Medicare in 2018, the Medicare Part D plans that you reviewed in 2016 or 2017, may not be available to you in 2018. If you find that a Medicare plan is available next year, the plans can (and probably will) have different costs, coverage, and healthcare providers. As an example, this graph shows the standard 2018 Medicare Part D plan parameters displayed first and then moves backward to the 2006 parameters from the beginning of the Medicare Part D program.
Bottom Line: Be prepared to review your Medicare plan options each year to ensure the most economic and complete coverage.
Tip: Remember, not all Medicare plans are available in all areas.
Medicare Part D and Medicare Advantage plans are offered in specific Service Areas, such as multiple-states, counties, ZIP Code areas, or parts of a highly-populated city such as New York or Los Angeles. Our Q1Medicare.com tools are designed to provide people with an overview of all Medicare plan options in their area or region.
Choosing a Medicare Part D or Medicare Advantage plan.
There is no one "right" way to choose a Medicare Part D or Medicare Advantage plan. In general, we simply advise people to choose a Medicare plan that most economically covers their current health and prescription needs. The Centers for Medicare and Medicaid Services suggests that you look at the factors of Coverage,
Cost, and Convenience - to these criteria we also add that you should
probably consider the Company and your level of Comfort.
But what if you do not need Medicare plan coverage?
- Coverage - Are your prescription medications covered by this
plan? Are there generic alternatives for your brand-name drugs? Can
you work with this plan to get a formulary exception should you need a
medication that is not covered on the existing formulary? How large (generous) is the Part D plan's formulary or drug list? What
price-tiers apply to your medications? What health coverage does the
Medicare Advantage plan offer beyond basic Medicare? What is the Medicare Advantage plan's maximum out-of-pocket limit (MOOP)? Are there any
additional coverage benefits offered by the plan?
- Cost - What are the monthly plan premiums? Does the Medicare
Part D plan or Medicare Advantage plan have an initial deductible?
Are there any drug tiers excluded from the deductible that would provide immediate coverage? What are the co-payments or co-insurance that you pay for your
medications or healthcare? What are the plan's coverage limits? Is
there any prescription coverage in the Donut Hole?
- Convenience - How difficult is it to find a pharmacy or a
health care provider? (Note: most Medicare Part D plans now have a
pharmacy network of 50,000 to over 60,000 pharmacies.) Does the Medicare Advantage plan have a restricted healthcare network? Do your doctors accept this Medicare Advantage
plan? How easy is it to work with this Medicare Part D plan or Medicare
Advantage plan when it comes to asking for Prior Authorization or exceptions to utilization management restrictions?
- Company - Is the company who provides the Medicare Part D or
Medicare Advantage plan important to you? Often people choose a
Medicare plan based only the Medicare plan provider's reputation or
recommendation. Does the company have a good quality star rating?
- Comfort - Are you comfortable with your current Medicare Part
D plan or Medicare Advantage plan? If you could find a more affordable Medicare plan, would you rather spend a few extra
dollars per month because you have an idea how your current Medicare
plan operates - and your plan costs are predictable - and you know that you can work with the plan? (Tip: If you are suggesting that your parents change Medicare plan coverage based on pure economics, be sure to understand your parent's level of comfort with their existing plan (doctors, pharmacists, specialists) - before persuading them to change Medicare plans.)
Still looking for more? Here are some general tips specifically for Medicare Part D prescription drug plan selection: Choosing a Plan: The Basics
Choosing a Medicare plan may be somewhat based on your risk tolerance. For instance, people who are not taking any (or only a few) medications, can look up the lowest costing Medicare prescription drug plan (or Medicare Advantage plan that includes prescription coverage), check for medication coverage, and decide whether they:
But what if taking financial risks is not an option to you?
- simply enroll in a Medicare plan with the lowest priced monthly premium just to avoid any future late-enrollment premium penalty or
- decide to pay a little more per month for a Medicare Part D plan with a $0 deductible and/or a larger formulary and/or a more familiar insurance company name - just in case their health were to change during the plan year or
- will not enroll in any Medicare Part D plan this year, save the monthly premiums, and plan to pay the late-enrollment penalty if they ever choose to join a Medicare Part D or Medicare Advantage plan in the future.
(Please Note: Yes, the monthly penalties can add up and here is a chart showing how your penalty costs can increase over time: https://q1medicare.com/q1group/MedicareAdvantagePartD/Blog.php?blog_id=579)
People with more complex medication or healthcare needs must spend more time ensuring that their specific needs are covered by a Medicare Part D or Medicare Advantage plan. For example, if you have a particular plan in mind (such as a local Medicare Advantage HMO that is provided by the large university or hospital system in your area), then you can review all of the coverage details we have online - and then call the plan to learn whether their healthcare providers are included in the Medicare Advantage plan's network.
Need a place to begin?
To get started, you can begin on our homepage (Q1Medicare.com) and see the box that is entitled "Review 201X Medicare Part D Plans" with a listing of state abbreviations for stand-alone Medicare Part D prescription drug plans. For example, if you live in the Commonwealth of Virginia, choose "VA", you will be taken to an overview of all Medicare Part D prescription drug plans in Virginia: https://q1medicare.com/PartD-SearchPDPMedicarePartDPlanFinder.php?state=VA
On this page, you can see the name of the Medicare Part D plans, the monthly premium, the initial deductible, and the co-payment rate for the different drug tiers.
Browsing a plan's formulary or drug list
If you wish to see the medications covered by this Medicare Part D plan, you can click on the "Browse Formulary" link on the right side of the chart. You can also click on the icons under the plan names for more plan details and plan contact information.
An example of using the Formulary Browser
Here is an example link to the first page of the Humana Walmart Rx Plan formulary in Virginia:
(IMPORTANT, Be sure to make sure you are looking at formulary or Medicare plan information for the current enrollment year).
From this Humana Walmart Rx Plan example link, you can see the medication names and packaging information, drug tier number, tier description, cost-sharing and usage management restrictions (if any). Using our Formulary Browser, you can always change the name of the Medicare Part D plan and state to browse other formularies.
Using the Drug Finder
You can also click on the icon after the drug name and you can see all of the Medicare Part D plans in Virginia that also cover this same medication and at what cost. (This is our Drug Finder tool (found at Q1Rx.com) and you can change the prescription name to whatever you wish.)
Finding a Medicare Advantage plan in your Zip Code region
If you are looking for a Medicare Advantage plan (with Medicare Part A, Medicare Part B, and possibly Medicare Part D coverage), you can start on the Q1Medicare homepage and choose the right-box entitled "Find a 201X Medicare Advantage Plan". You can then enter your Zip Code or choose the state and county to see the Medicare Advantage plans available in your chosen Service Area. (Medicare Part D plans are available state-wide, Medicare Advantage plans are offered on a ZIP Code or county area or partial-county area.)
An example of the Medicare Advantage plan finder
As an example, here are the Medicare Advantage plans available in Fairfax County, Virginia:
Again, you can see the basic coverage details of all these Medicare Advantage plans in the list, along with Medicare Part D prescription drug coverage details, if included on the plan (or MAPD). The icon below the Medicare Advantage plan name that looks like a small stack of paper will show all of the coverage details for a specific Medicare Advantage plan.
More help? Browse our Frequently Asked Questions
If you have specific questions, you can always browse our FAQ section found here: https://q1medicare.com/FAQ.php
The Medicare & You Handbook online with additional information
We also have the CMS Medicare & You Handbook online, alone with our supplemental notes and information: https://q1medicare.com/PartD-MedicareAndYouCMSGuideToMedicare.php
When you need to speak with someone about your plan options or are ready to enroll
If you feel lost or overwhelmed along the way, you can always contact Medicare directly at 1-800-633-4227 (1-800-Medicare), select the prescription drug option, and then choose the option to speak with a Medicare representative or say "representative" during the menu options.
Once connected, you can explain your situation to a Medicare representative and ask them to help you find a Medicare Advantage plan or Medicare Part D prescription drug plan that most economically covers your health and medication needs - or you can ask specific questions about a particular Medicare plan or the Medicare Part D program in general.
If you find a suitable Medicare Advantage plan or Medicare Part D plan and are eligible to enroll into the plan, the Medicare representative can process your enrollment into your chosen Medicare plan directly over the telephone - and the process only takes a few minutes. A Medicare representative is not compensated for a Medicare plan enrollment and provides you with an unbiased view of all available Medicare Part D plans or Medicare Advantage plans.