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Medicare Part D Prescription Drug and
Medicare Advantage plan Tools

New to the Medicare Part D and Medicare Advantage plan program?

The following is a brief introduction to Medicare Part D plans and Medicare Advantage plans, along with an overview of some of our online tools that will help you review Medicare plans in your area.



What is Medicare Part D?  Need some extra help?
You can use our Customer Helpdesk to send us a question. If we cannot answer your question, we will try to direct you toward someone who should be able to help. You can also browse our Medicare Part D Frequently Asked Questions (FAQs)




What is Medicare Part D?

Medicare Part D is simply a government program that provides insurance for your prescription medications (just like insurance for your car) and this means that you should pay less for your prescriptions when you have a Medicare Part D prescription drug plan (just like when you receive coverage from your automobile insurance).

There are two general ways that you can receive Medicare Part D prescription drug coverage:
  • stand-alone Medicare Part D prescription drug plans (or PDPs) - PDPs only provide drug coverage and

  • Medicare Advantage plans that include prescription drug coverage (MAPDs). Medicare Advantage plans actually come with (MAPDs) and without drug coverage (MAs). All Medicare Advantage plans (MAs and MAPDs) provide your Medicare Part A coverage (Medicare coverage for in-patient and hospitalization care) and your Medicare Part B coverage (Medicare covered doctor visits and out-patient care) - and sometimes other benefits such as limited optical, hearing, dental, and fitness coverage. And, as noted, some Medicare Advantage plans include Medicare Part D prescription drug coverage (MAPDs).

    Again, this means that you can receive Medicare Part D prescription drug plan coverage from both Medicare Part D plans (PDPs) and Medicare Advantage plan (MAPDs).
And, aside from the Medicare Part D progam, there are also other ways to receive insurance for your prescription drugs, for example:
  • You can also receive drug coverage from your Employer Health plan. The key is to ensure that any Employer Health plan provides "creditable" prescription drug coverage so that you avoid any Late-Enrollment Premium Penalties.  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.
    or

  • Drug coverage provided by the Veterans Administration (VA). VA drug coverage is actually very important because this coverage actually provides benefits alone VA coverage can work together with a Medicare Part D plan. You can read more in our Frequently Asked Questions.

Reminder: Medicare has several sections that you may see as shortened to abbreviations:
  • Medicare Part A is the part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care. Most people do not have to pay a monthly Medicare Part A premium because of their work experience or disability. For more information, we provide a chart of the Medicare Part A premiums and deductibles for past years..
  • Medicare Part B is out-patient medical insurance, and according to the Centers for Medicare and Medicaid Services (CMS) is defined as: Medicare medical insurance that helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Medicare Part A. You pay a monthly premium for your Medicare Part B coverage that can change every year. Your monthly premium for Medicare Part B is also based on your income and may increase based on the Income-Related Monthly Adjustment Amount (IRMAA). We provide a charts showing the Medicare Part B monthly premiums for past years..
  • Medicare Part C refers to Medicare Advantage plans (MAs and MAPDs). Medicare Advantage plans are health plan options that are approved by Medicare but run by private insurance companies and provide Medicare Part A and Medicare Part B coverage (and even Medicare Part D coverage (MAPDs)). Medicare Advantage plans are not Medicare Supplements and you can not use these two different health plans together. Medicare Advantage Plans are offered in different forms, such as:
    • Health Maintenance Organization (HMO)
    • Health Maintenance Organization with a Point of Service Option (HMO POS)
    • Preferred Provider Organization (PPO)
    • Private Fee-For-Service (PFFS)
    • Medicare Special Needs Plans (SNPs)
    • Medicare Medical Savings Account (MSAs)
  • Medicare Part D plans provide prescription drug covered offered by private insurance companies and are available as stand-alone plans (PDPs) or Medicare Advantage plans that include drug coverage (MAPDs).

And ... You pay a monthly premium for your Medicare Part D coverage that can change every year. Your monthly premium for Medicare Part D (like Medicare Part B) is also based on your income and may increase based on the Income-Related Monthly Adjustment Amount (IRMAA).

For more information, please also see:



How does Medicare drug coverage work?

Your Medicare Part D prescription drug plan coverage is divided into four phases or parts. As you purchase medications that are covered by your Medicare Part D plan, you will move through these phases and your coverage will change depending on each phase. Also, depending on your prescription drug spending, you may never reach all four of your Medicare Part D plan's phases.
  • (1) The Initial Deductible phase is where you pay 100% of your retail drug costs until you reach your deductible amount (for instance, $400 in 2017).  Many people will enroll in a Medicare prescription drug plan with a $0 deductible and effectively skip-over this first phase.  Also, some Medicare Part D plans will exclude less-expensive drugs (such as Tier 1 generics) from the plan's initial deductible, so coverage for some drugs begins even though you have not met the initial deductible.

  • (2) The Initial Coverage phase is where you and your Medicare Part D plan 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: the Initial Coverage Limit is measured by the total retail value of your prescription drug purchases. For example,if you buy a $100 prescription and pay a $30 co-pay (the Medicare Part D plan pays the other $70), the total $100 retail cost is credited toward your Initial Coverage Limit.

  • (3) The Coverage Gap or Donut Hole is the plan phase you enter once you exceed the Initial Coverage Limit and where 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.

  • (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 $4,950 in 2017). During this phase you receive your medications at a low-fixed price, paying around 5% of the retail drug price for the remainder of the year.

A little more about the Donut Hole Discount ... How does the Donut Hole discount work?
If you reach the Donut Hole in 2017 (you have retail drug costs over $308 per month, you will received a 60% discount on brand-name drugs and a 49% discount on generic drugs (you will pay 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.


A little more about Total out-of-pocket costs (TrOOP) ... TrOOP is the Donut Hole exit point and is what you have personally spent out of pocket for medications, but does not include your monthly premiums. Also, although you receive a 60% discount on brand drugs in the 2017 Donut Hole (you pay 40% of retail), you will actually get 90% of the retail price credited toward your TrOOP. So if you purchase a brand name drug in the 2017 Donut Hole with a retail cost of $100, you pay $40 (you get 60% discount in 2017) and you get $90 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.)


A little more about Retail drug cost and what you actually spend (TrOOP). You will enter the Donut Hole or Coverage Gap based on the retail value of the prescription drugs that you purchase. If you purchase medications worth over $3,700, you will enter the Donut Hole. Usually, you will spend around 25% of the retail price, so you will enter the 2017 Donut Hole when you have spent around $925.
You will exit the Donut Hole and enter Catastrophic Coverage based on the actual amount that you have spent out of pocket. If you spend more than $4,950 in 2017, you will exit the Donut Hole and enter Catastrophic Coverage. When you exit the Donut Hole, Medicare estimates that you will have purchased medications with a retail value of around $8,071.



Review your monthly Explanation of Benefits letter for details of your coverage and spending.
What? How could anyone follow all this?
No worries. Your Medicare plan will keep track of your drug spending and will send you an "Explanation of Benefits" letter each month detailing your purchases and where you are within your Medicare Part D plan coverage.




When can you enroll into a Medicare Part D or Medicare Advantage plan?

There are several enrollment periods that are available to you when you wish to join or change Medicare Part D or Medicare Advantage plans.

  • Initial Enrollment Period (IEP) is a seven (7) month window beginning three (3) months before your month of Medicare eligibility, plus the month of Medicare eligibility, and ends three (3) months after your month of eligibility. If you enroll during the three months prior to your month of Medicare eligibility, your effective date is the 1st day of your month of eligibility. If you enroll into a Medicare Part D plan during your month of eligibility (such as when you turn 65 years old) 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 enrollment.

  • The annual Open Enrollment Period or Annual Coordinated Election Period (AEP) is available for all people who are already eligible for Medicare and allows people to choose a new Medicare plan each year. The AEP 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 (SEPs) are available for people to change Medicare plans when they are outside of their IEP or AEP. 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 blog for more details and examples of SEPs.




How do I enroll in a Medicare Part D plan?

If you wish to join a Medicare Part D prescription drug plan (or Medicare Advantage plan), we suggest you speak with a Medicare representative about your Medicare plan eligibility and options.

To contact Medicare directly please call toll-free 1-800-633-4227, select the prescription drug option, and then choose the option to speak with a Medicare representative or say "representative" several times during the automated menu options.

Once connected, please explain your situation to a Medicare representative and ask the Medicare representative whether you are eligible to join a Medicare plan at this time.

If you are eligible for enrollment, ask the representative to help you find a Medicare Advantage plan or a 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.

As you review plan options, you can ask the representative to provide you with an estimated annual cost based on your health and medication needs for any particular Medicare plan.

You can also make sure that the Medicare representative knows about the pharmacies you use or have available (and explains to you about the possible cost differences between preferred and non-preferred network pharmacies).

If you are enrolling into a Medicare Advantage plan, please be sure that your healthcare providers are included in the plan's network.

If you have found an acceptable Medicare plan, and you are eligible for enrollment, the Medicare representative can also process your enrollment into any Medicare Part D or Medicare Advantage plan directly over the telephone - and the process only takes a few minutes (with an enrollment confirmation code provided).

Please note that 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.

To search for a Medicare Part D plan in your area by plan features such as premium, deductible, etc., please use this link:  https://q1medicare.com/PartD-SearchPDPMedicarePartDPlanFinder.php




How much will a Medicare Part D plan cost?

  • 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 - and will change each year. You can see a list of all Medicare Part D plans in your state using our Medicare Part D Plan Finder (Florida Example). You can see a list of all Medicare Advantage plan in your ZIP Code region using our Medicare Advantage Plan Finder (Pittsburgh, PA Example). You can also learn about the Medicare Part D plan premiums in your area by calling a Medicare representative at 1-800-633-4227.

  • Your Drug Costs: When you are in your initial deductible phase, you will pay the full negotiated retail price for medications, until the deductible amount is met. In the Initial Coverage phase, you will share the cost of medications with your Medicare plan. This "cost-sharing" can be in the form of "co-payment" or "co-insurance"

  • Co-payment: This form of cost-sharing has a fixed amount for all drugs in a specific formulary tier (or drug list gorup). So you may pay $30 for brand-name drugs or $60 for all preferred brand-name drugs. The fixed co-pay will not change throughout the plan year, even if the retail price of the medication changes. If you have a drug that has a retail price lower than the co-pay, then you pay no more than the retail price (you never pay over retail).

  • Co-payment: Many Medicare Part D plans offer co-insurance as cost-sharing and this means you will pay a portion of the retail price. For instance, 25% or 35% of retail. If the retail price of a drug increases throughout the plan year, the your cost-sharing will increase.
    Tip: Many people find that Medicare Part D plans using co-insurance are affordable in January, and not-so-affordable in August.

  • Medicare Advantage plan healthcare costs: If your Medicare Part D coverage is provided by a Medicare Advantage plan (MAPD), then you will also use the plan for Medicare Part A and Medicare Part B coverage. Some Medicare Advantage plans provide almost identical coverage as Original Medicare, other Medicare Advantage plans have fixed co-pays for the different Medicare services they provide.
    Tip: If you have complex healthcare needs, be sure to study the coverage provided by a Medicare Advantage plan before enrolling.




Financial assistance is available.

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 beneficiaries 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.




Need a place to get started?

To get started, you can begin on our homepage (Q1Medicare.com) and see the box that is entitled "Review 2017 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-SearchPDPMedicare-2017PlanFinder.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.

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.

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 2017 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.)

As an example, here are the Medicare Advantage plans available in Fairfax County, Virginia:
https://q1medicare.com/PartD-SearchMA-Medicare-2017PlanFinder.php?state=VA&countyCode=51059&showCounty=Fairfax

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.




Tools for finding a Medicare Part D prescription drug plan ...

PDP-Finder - Prescription Drug Plan Finder: Search by plan features and premiums across all stand-alone Medicare Part D plans:   2017 plans  2016 plans

PDP-Compare - Compare how each Medicare Part D plan changes from one year to the next: 2016 to 2017 Medicare Part D plan feature comparison  2015 to 2016 Medicare Part D plan feature comparison

MA-Finder: Medicare Advantage Plan Finder:   2017 plans   2016 plans

MA-Compare - Compare how every Medicare Advantage plan changes from one year to the next: 2016 to 2017 Medicare Advantage plan feature comparison  2015 to 2016 Medicare Advantage plan feature comparison

Guided Help Finding a Prescription Drug Plan:   2017 plans   2016 plans

Many more tools can be found in the navigation on the left-hand side of the page ...




Browse all the medications covered by your Medicare drug plan (PDP) or (MAPD)

Review cost-sharing, quantity limits, prior authorization, and step therapy requirement for every covered prescription medication offered by your Medicare Part D (PDP) or Medicare Advantage plan (MAPD).

Medicare Part D Formulary (Drug List) Browser:
2017 plans   2016 plans




Compare the coverage of a medication across all Medicare drug plans (PDP) and (MAPD)

See how each plan in your service area covers your medication including cost-sharing, quantity limits, prior authorization, and step therapy requirements

Compare Medicare Part D or Medicare Advantage Plans by Drug:
2017 plans   2016 plans




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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.