Medicare Part D Drug Benefit Eligibility

Fact Checked

Medicare Part D is Medicare’s prescription drug coverage program. There are specific rules about what prescription drugs Medicare Part D will cover and how much of each medication it will cover, which can vary based on your specific Medicare plan and situation. Learn the rules on who is eligible for Medicare Part D, when you should enroll in Part D to maximize your benefits, and who does not qualify for Medicare Part D.

Who is Eligible for Medicare Part D Drug Benefits?

Part D prescription drug coverage is offered through Original Medicare, so anyone who is eligible for Medicare is also eligible for Medicare Part D drug benefits. According to, everyone with Medicare, no matter your income level, health status, or prescription drug usage, has access to prescription drug coverage. You are eligible for Medicare Part D drug benefits if you meet the qualifications for Medicare eligibility, which are:

  • You are age 65 or older
  • You have disabilities
  • You have end-stage renal disease

You can enroll in Medicare Part D as soon as you are eligible for Medicare and even if you have other prescription drug coverage. In fact, you will want to enroll in Medicare Part D as soon as you are able to avoid a late enrollment penalty. There are specific enrollment periods for Medicare Part D based on when you join Medicare and for certain extenuating circumstances, but essentially, you will want to join Part D as soon as you are eligible.

When Should I Enroll in Medicare Part D to be Eligible For Benefits?

Medicare Part D is an optional part of Medicare. Even if you do not currently need prescription drug coverage,, it is recommended that you still enroll in Part D as soon as you are eligible, so you’re covered when and if you do require prescription medication. If you opt to delay enrolling in Medicare Part D because you don’t currently require prescription drug coverage or have another health insurance plan that you’re using instead of Medicare, you will most likely pay a late enrollment penalty if you do enroll later.

The late enrollment penalty isn’t just a one-time cost. It is a permanent cost that will be added to your Medicare Part D premium for as long as you use Medicare. You may have to pay the late enrollment penalty if there is a lapse in your prescription drug coverage for 63 days or more past your Initial Enrollment period. That includes if you simply opt out of the coverage when you initially enroll in Medicare, or if you had another insurance plan you were using for prescription medication that runs out and leaves you without creditable prescription drug coverage for 63 days or more.

The exact amount you will pay for a late enrollment penalty will vary based on the number of months you went without drug coverage and a national yearly based premium, which usually changes every year. In general, to calculate a late enrollment penalty, Medicare will multiply 1% of the current national base beneficiary premium–which again, can change every year. It is $33.37 in 2022.

For example:, if you went 10 months without coverage and enrolled late, your penalty would look like: $33.37 x .10 (1% multiplied by 10) = $3.34.

Who Isn’t Eligible for Medicare Part D?

Everyone who is eligible for Medicare is eligible for Part D prescription drug coverage. However, you can also choose to receive Medicare prescription drug coverage through a Medicare Advantage Plan, or Medicare Part C.

You cannot have both a Medicare Advantage plan (Part C) with drug coverage and Part D (drug coverage) at the same time. If you have Part D and decide to join a Medicare Advantage plan with drug coverage, your Part D coverage will stop as soon as your new coverage in the Medicare Advantage plan begins. If you have a Medicare Advantage plan with drug coverage and decide to join a Part D plan, you will be disenrolled from the Medicare Advantage plan and returned to Original Medicare.

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Medicare consultant, AAPC National Advisory Board

Caren Lampitoc has worked in health care since 1982, beginning her career as a surgical technologist with the United States Navy. As a Navy hospital corpsman, she gained clinical experience in the operating room and surgical clinics. She then transitioned to the civilian world, studying at Montgomery College and working in doctors’ offices in various subspecialties as well as auditing and risk adjustment.

Lampitoc became a medical coder in 1999 and has served as an instructor and national speaker since 2006. She served on the AAPC National Advisory Board from 2015 to 2018, and her professional certifications included Certified Professional Coder/Physician, Certified Medical Auditor, and Certified Professional Biller.

Her passion is education and training as well as helping providers understand proper documentation and coding. Understanding Medicare policy is always part of the education for providers. Moving into her current position as a Medicare consultant brought her career full circle from clinical service to the office and now to the payer.

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