A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

Am I required to use my Medicare Part D plan when buying my prescriptions?

Category: Living with Your Medicare Part D Plan
Updated: Jun, 06 2023


No.  You are not required to use your Medicare Part D plan even when you are buying a formulary drug at one of your Medicare plan's network pharmacies.

However, except in certain situations (explained below), you may not be reimbursed for any drug purchases you make without using your Medicare Part D plan.

Cash Purchases without the Donut Hole Discount
Also, if you do not use your Medicare Part D plan when purchasing your medications at a network pharmacy, you will not be able to take advantage of the Donut Hole or Coverage Gap discount.  As noted by the Centers for Medicare and Medicaid Services (CMS):
 
"Part D sponsors shall provide the applicable [Donut Hole] discount for out-of-network paper claims submitted by Part D enrollees. However, the discount shall not apply to in-network claims that were not submitted electronically by the pharmacy for any reason other than the pharmacy was technically unable to process claims on the date of service through no fault of the beneficiary. This means that beneficiaries that choose to have a prescription filled for a “better cash price” that is not processed through the Part D sponsor will not receive a manufacturer discount under the Discount Program on such prescription." [emphasis added]

(Source: CMS Memo, April 30, 2011, Medicare Coverage Gap Discount Program beginning in 2011, Section 70.5 Point-of-sale Exceptions, https://www.cms.gov/ Medicare/ Prescription-Drug-Coverage/ PrescriptionDrugCovContra/ downloads/ 2011CoverageGapDiscount_043010v2.pdf)



Seeking reimbursement for in-network pharmacy purchases without using your Medicare Part D plan.
As noted in the Medicare Prescription Drug Benefit Manual Chapter 14:

"Although beneficiaries can still purchase a covered Part D drug at a network pharmacy without using their Part D benefit or a supplemental card, CMS encourages beneficiaries to use their Part D benefit. Use of the benefit affords beneficiaries access not only to the plan’s negotiated prices, which in most cases are the lowest price available, but also to the plan’s drug utilization review and other safety edits that only can be provided when the plan adjudicates the claim. Beneficiaries who choose to make a cash purchase will continue to be responsible for submitting documentation to the plan for determination of whether they are eligible for reimbursement and for costs to be included in gross covered drug costs and [total out-of-pocket costs] TrOOP.  Guidance included in section 50.4.3 below [of chapter 14] replaces CMS’ former cash purchase policy and clarifies plan processing of beneficiary -submitted claims for cash purchases as well as enrollee costs and amounts to be included in the enrollee’s gross covered drug costs and TrOOP. " [emphasis and links added]

(Section 50.4.2 – Beneficiary Cash Purchases (Rev. 17, Issued: 08-23-13, Effective Date: 06-07-10, Implementation Date: 1-01-11)) (https://www.cms.gov/ Medicare/ Prescription-Drug-Coverage/ PrescriptionDrugCovContra/ Downloads/ Chapter14.pdf)

We wrote about the CMS "cash purchase policy" in three different articles (2006, 2010, and 2013) - and as noted in 2013: "Previously, CMS permitted enrollees to purchase a covered Part D drug without using his or her Part D benefit or a supplemental card and have the cash price count toward the enrollees’ total drug spending and TrOOP. The policy applied if the enrollee could obtain a lower price at a network pharmacy than the plan’s negotiated price in any applicable deductible or coverage gap when the enrollee incurs 100 percent of the drug cost.":



A few notes about seeking reimbursement when you do not use your Medicare Part D plan to purchase medications:

As was noted above, the Medicare Part D program is voluntary and you are not required to purchase medications using your Medicare Part D plans.   But if you do not use your plan (e.g., you use a pharmacy discount card), the drug purchases fall outside of your Medicare Part D plan.

This means that if you have purchased your medications and did not use your Medicare Part D prescription drug plan, then the cost of the medications will not be counted toward your initial deductible (if any), nor will the purchase count toward your total out-of-pocket costs (TrOOP). The logic here is that your Medicare plan simply has no way to track such purchases outside of their reporting system.

So in past years, there was a provision that allowed people to submit their purchases for reimbursement and inclusion within their Medicare Part D plan. The rule behind this is called the Lower-Cash Pricing Policy and can be found here:  CMS Memorandum: Lower Cash Price Policy

But, in past years, Medicare has changed this policy and, as noted in the Medicare Prescription Drug Benefit Manual (Chapter 14, Section 50.4.2):

“Previously, CMS permitted enrollees to purchase a covered Part D drug without using his or her Part D benefit or a supplemental card and have the cash price count toward the enrollees’ total drug spending and TrOOP. The policy applied if the enrollee could obtain a lower price at a network pharmacy than the plan’s negotiated price in any applicable deductible or coverage gap when the enrollee incurs 100 percent of the drug cost. The enrollee was required to submit the appropriate documentation to his or her plan for the incurred drug cost to be included in gross covered drug cost and TrOOP.

Since the beneficiary cash purchase policy was issued, the Part D benefit has undergone significant change. Beginning January 1, 2011, the changes created by the Affordable Care Act (the ACA) started closing the coverage gap for beneficiaries not receiving LIS. By establishing the Coverage Gap Discount Program, which makes manufacturer discounts available at point-of-sale to non-LIS beneficiaries in the coverage gap, and gradually increasing coverage in the coverage gap for both generic and brand name drugs and biologics, the ACA for the most part has eliminated the need for this policy.

[As already noted above:] Although beneficiaries can still purchase a covered Part D drug at a network pharmacy without using their Part D benefit or a supplemental card, CMS encourages beneficiaries to use their Part D benefit. Use of the benefit affords beneficiaries access not only to the plan’s negotiated prices, which in most cases are the lowest price available, but also to the plan’s drug utilization review and other safety edits that only can be provided when the plan adjudicates the claim. Beneficiaries who choose to make a cash purchase will continue to be responsible for submitting documentation to the plan for determination of whether they are eligible for reimbursement and for costs to be included in gross covered drug costs and TrOOP. Guidance included in section 50.4.3 below replaces CMS’ former cash purchase policy and clarifies plan processing of beneficiary-submitted claims for cash purchases as well as enrollee costs and amounts to be included in the enrollee’s gross covered drug costs and TrOOP.”

In the next Section 50.4.3, the guidance continues and establishes that Medicare Part D plans will restrict the Lower Cash Pricing reimbursement model only to situations where no network pharmacy is available to the plan Member:

“CMS regulations and guidance specifically address the requirement for Part D sponsors to issue standardized cards that may be used by an enrollee to ensure access to negotiated prices under section 1860D - 2(d) of the Act. The only way that an enrollee can be assured access to the negotiated price at the point of sale is through online adjudication of the prescription drug claim. Therefore, to ensure access to these negotiated prices, the billing information on the standardized cards issued by the Part D sponsor must be used by the pharmacies at which beneficiaries fill their prescriptions to submit claims to an enrollee’s plan sponsor (or its intermediary). Thus, another price available to the beneficiary at the point of sale, for instance, the pharmacy’s “cash price,” would not be the negotiated price because it is not accessed by the use of the standardized card.

CMS encourages beneficiaries to use the Part D benefit, because generally it believes it is in the best interest of Part D enrollees to have their claims consistently processed through the Part D sponsor (or its intermediary). Not only does processing claims through the Part D sponsor ensure access to Part D negotiated prices, but it also ensures that proper concurrent drug utilization review (including safety checks) is performed (as required under 1860D - 4(c) of the Act). Only the plan can prevent payment to excluded providers or conduct accurate concurrent drug utilization review when a beneficiary uses multiple pharmacies. Online, real-time processing also facilitates accurate accounting for enrollees' true out-of-pocket (TrOOP) and total drug costs by the Part D sponsor so that each claim is processed in the appropriate phase of the benefit and accurate cost sharing assessed.

Guidance in section 50.4 of this chapter instructs plan sponsor s to process all claims online and in real time. The requirements of accurate TrOOP accumulations, Part D benefit administration of multiple coverage intervals, and coordination of benefits with other payers all necessitate online, real-time adjudication of individual pharmacy claims. This guidance states further that CMS expects Part D sponsors will establish policies and procedures appropriately restricting the use of beneficiary-submitted paper claims to those situations in which online claims processing is not available to the beneficiary at point-of-sale (such as out-of-network pharmacies) in order to promote accurate TrOOP accounting as well as to minimize administrative costs to the Part D sponsors and the Medicare program and reduce opportunities for fraudulent duplicative claim reimbursements.” [emphasis added]

You can read more from the Medicare Part D manual here: https://www.cms.gov/ Medicare/ Prescription-Drug-Coverage/ PrescriptionDrugCovContra/ Downloads/ Chapter14.pdf

For example:  A Medicare Advantage plan's Evidence of Coverage (EOC) document might note in the section: “When you buy the drug for a price that is lower than our price” (see, Chapter 7, Section 4.1) that you will not be reimbursed for the cost of your discounted drug purchases, but you can submit the purchase receipts when you are in the Donut Hole for credit toward TrOOP:

“Sometimes when you are in the Coverage Gap Stage you can buy your drug at a network pharmacy for a price that is lower than our price.

• For example, a pharmacy might offer a special price on the drug. Or you may have a discount card that is outside our benefit that offers a lower price.

• Unless special conditions apply, you must use a network pharmacy in these situations and your drug must be on our Drug List.

• Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage.

• Please note: If you are in the Coverage Gap Stage, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly.“

Bottom Line:
You are not required to use your Medicare Part D plan when purchasing formulary medications at a network pharmacy.  But you may not be reimbursed for any of your costs associated with these purchases as it seems as though the former "Lower Cash Pricing Policy" has been eliminated (or limited to emergency out-of-network situations) so that more people will rely on the Medicare plan’s electronic record keeping system.  And you probably will not be able to retroactively submit your in-network claims to receive the Donut Hole discount.

Disclaimer:  Please contact your Medicare Part D plan or Medicare (1800-633-4227) for a further clarification.





Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs


Browse FAQ Categories






Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.