You will pay the Tier 1 or Tier 2 co-payment for your medications, if these two formulary tiers are excluded from the initial deductible - even when the plan's initial deductible
is not yet met.
Example for Tier 1 and Tier 2 drugs excluded from the initial deductible.
An increasing number of Medicare Part D plans
exclude Tier 1 and Tier 2 drugs from the plan's initial deductible and
these low-costing drugs are not impacted by your initial deductible and
have immediate coverage. So, if you have a $480 standard deductible with Tier 1 and Tier 2 drugs excluded, and you purchase a Tier 2 generic drug
that has a retail price of $15 (with a co-pay of $3) – you pay only the $3 co-pay and your $480 deductible is not affected.
However, if your Medicare Part D plan does not exclude any tiers from the initial deductible, then you must pay your Medicare Part D plan's initial deductible before you receive any coverage from your Medicare Part D plan.
example, the standard 2022 Medicare Part D deductible
is $480 and
you must pay the full retail price for your formulary drugs until you have spent $480 out of pocket. When the initial deductible is met, then the Medicare plan coverage
begins and you will only pay a portion of the retail drug cost.
As a note of interest . . .
In this example above with Tier 1 and Tier 2 drugs excluded from the deductible, if you were to only purchase Tier 1 and Tier 2 drugs all year, your $480
deductible would never be met. But, if your total retail drug cost
exceeds your Initial Coverage Limit ($4,430 in 2022), you would still enter your plan's Coverage Gap or Donut Hole - and continue to move through your plan's coverage.
Example for a typical Tier 3 drug impacting the initial deductible.
If you have a Tier 3 formulary medication
that costs $340 (retail) and your Medicare plan has a standard 2022 deductible of $480
– and the Tier 3 medication has a $43 co-pay, you would pay full retail
of $340 and you would have a deductible balance of $140 ($480 - $340). And the full $340 retail value of the formulary drug would count toward reaching your plan's Initial Coverage Limit
and entering the Donut Hole or Coverage Gap.
Question: How do you know whether a Medicare plan excludes Tier 1 and Tier 2 drugs from the initial deductible?
You will notice when you visit our Medicare Part D Plan Finder
) that Medicare Part D plans will be marked under the "Deductible" section with the text "Tier 1 exempt" or "Tier 1 and 2 exempt".
Here is an example of 2021 Medicare Part D plans having lower-costing generics excluded from the standard deductible.
And here is an example of a 2022 Medicare Part D plan having Tier 1, Tier 2, Tier 3, and Tier 6 drugs excluded from the plan's initial $100 deductible.
In addition, when you view the Medicare plan details (by clicking on the Medicare plan name), you can see in the plan details that Tier 1 and Tier 2 drugs may be excluded from the plan's initial deductible.
As an example using the Q1Rx Drug Finder, in 2022, Florida has 22 stand-alone Medicare Part D plans
that cover “MONTELUKAST SOD 10 MG TABLET [Singulair] (30 TABLETS) (NDC: 65862057490)” and you can click on the Medicare plan name
to see more details of the coverage for a particular plan.
In the Q1Rx Drug Finder, you can see that some drugs are marked as (1*
) and this means that the Tier 1 or Tier 2 drug has is excluded from the plan's initial deductible - and receives coverage according to the cost-sharing.
Need more help? Contact your plan and review your plan's documentation.
You can learn more by contacting your Medicare Part D prescription drug plan by calling the toll-free number for Member Services found on your Member ID card.
You can also read more about your drug plan coverage in your Medicare plan's Evidence of Coverage document where you might find in Chapter 4, "What you pay for your Part D prescription drugs":
"During the Deductible Stage, you pay the full cost of your Cost-Sharing Tier 3, Cost-Sharing Tier 4, and Cost-Sharing Tier 5 drugs" and then, "You stay in the Deductible Stage until you have paid $445 for your Cost-Sharing Tier 3, Cost-Sharing Tier 4, and Cost-Sharing Tier 5 drugs".
Further on in the Evidence of Coverage Chapter 4 you can read:
"The Deductible Stage is the first payment stage for your drug coverage. You will pay a yearly deductible of [annual deductible amount] on Cost-Sharing Tier 3, Cost-Sharing Tier 4, and Cost-Sharing Tier 5 drugs. You must pay the full cost of your Cost-Sharing Tier 3, Cost-Sharing Tier 4, and Cost-Sharing Tier 5 drugs until you reach the plan's deductible amount. For all other drugs you will not have to pay any deductible and will start receiving coverage immediately.
The Initial Deductible and the Donut Hole.
• Your "full cost" is usually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs.
• The "deductible" is the amount you must pay for your Part D prescription drugs before the plan begins to pay its share.
Once you have paid [the annual deductible amount] for your Cost-Sharing Tier 3, Cost-Sharing Tier 4, and Cost-Sharing Tier 5 drugs, you leave the Deductible Stage and move on to the next drug payment stage, which is the Initial Coverage Stage."
Remember, your Medicare Part D plan's Initial Deductible does not affect
when you enter the Donut Hole or Coverage Gap. You enter the Donut Hole based on the retail value of the prescriptions you purchase - not the coverage cost (what you pay).
However, your Initial Deductible (your out-of-pocket spending) will impact
how quickly you exit the Donut Hole. You can click here to read more about the impact of your Initial Deductible