Medicare Part D: Prescription drug coverage

Helps pay for prescription drugs

You can get prescription drug coverage with a standalone Part D plan or with a Medicare Advantage plan that includes prescription drug coverage.

What Part D covers

Medicare Part D plans cover:

Types of drugs most commonly prescribed for Medicare beneficiaries as determined by federal standards

Specific brand name drugs and generic drugs included in the plan’s formulary, or list of drugs

Commercially available vaccines not covered by Part B

Save money on your prescriptions by

Pharmacy Network

You may receive additional discounts on your prescriptions by using a preferred retail pharmacy or by using the mail service pharmacy and having your medications delivered to your mailbox.

Drug list (formulary)

A drug list is a list of the drugs that a plan covers. Each plan has its own drug lists you can get.

Start Step Therapy

You may be asked to try one or more lower-cost drugs before a plan will cover the brand name drug you are currently taking.

Use Quantity Limits

Some drugs have quantity limits, where the plan will cover only a certain amount of a drug for one copay or over a certain number of days. The limits may be in a place to ensure safe and effective use of the drug. If your doctor prescribes more or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Ask For Prior Authorization

Before the plan will cover certain drugs, it may need more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. You may be required to try a different drug before the plan will cover the prescribed drug.

Exception for prescription drug coverage

Asking for your exception

If you need a drug that’s not currently covered by your plan, you may:

Ask the plan to cover your drug even if it is not on the drug list. This is know as a formulary exception.
Ask to waive coverage restrictions or limits on your drug. This is know as a utilization exception.

Coverage Decisions

If your doctor has submitted an exception request on your behalf, generally the plan will make a decision within 72 hours. You can request an expedited, or fast, decision if you or your doctor believes your health requires it.

Using your Plan:

Know the formulary

Make sure the medications you take are on the plan formulary. Check with your doctor to see if there’s a covered drug you can switch to if needed.

Consider generics.

Ask your provider about generic or low -cost options if your drug is in a high tier or is too expensive.

Show your member ID card

Be sure you take advantage of the discounted plan prices when you fill a prescription.

Use the mail-order pharmacy

You may get savings and convenience when you order 3-month supplies of your medications.

Use a network preferred pharmacy

Save with low prices offered with many plans.

What you pay for Part D

Premium

Standalone Part D plans charge a premium, and each plan sets the amount it charges. Medicare Advantage plans with drug coverage generally charge one premium for all benefits — medical, hospital and prescription drugs.

Deductible

Some plans charge a deductible and others do not. Plans may also have a deductible for some drugs and not for others. Deductible amounts could also vary from one drug tier to another.

Medicare sets a maximum deductible amount each year. The maximum annual deductible a Part D plan may charge in 2019 is $415.

Copay

A copay is generally required each time you fill a prescription for a covered drug. Copay amounts usually vary based on a plan’s formulary tiers – the lower the tier, the lower the cost. Copay amounts may also vary depending on which pharmacy you use.

Each plan sets its own copay terms and amounts, and these can vary widely from plan to plan.

Coinsurance

Copays are more common, but some plans may set coinsurance rates for certain drugs or drug tiers.

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Total drug costs

The amount you (or others on your behalf) and your plan pay for your prescription drugs. Your plan premium payments are not included in this amount.

Out-of-pocket costs

The amount you (or others on your behalf) pay for your prescription drugs plus the standard 50% discount on your brand name drugs provided by drug manufacturers. Your plan premium payments are not included in this amount.

If you get Extra Help from Medicare, the coverage gap doesn’t apply to you.

Extra Help is a program for people with limited incomes who need help paying Part D premiums, deductibles and copays. To see if you qualify for Extra Help, call us.