Find Medicare Part D Prescription Drug Plan Coverage

Fact Checked

Original Medicare Parts A and B do not include prescription drug coverage (Part D). When you are enrolled in A and B, you may need to join a Medicare plan that covers prescription drugs. You have the option of getting drug coverage one of these ways:

  • A stand-alone drug coverage Part D plan that is administered by Medicare-approved private insurance companies. You must be enrolled in Part A and/or B to join a stand-alone Part D plan.
  • Through a Medicare Advantage (Part C) Plan or other Medicare health plan that includes a prescription drug benefit. You must be enrolled in Part A and B to join a Medicare Advantage Plan with drug coverage (MA-PD).
  • Keep your current prescription drug coverage as long as it is creditable coverage, such employer or union drug coverage, or get Extra Help. You can avoid paying late enrollment penalties if you need a stand-alone Part D plan, Part C, or Medicare Health plan later.

Who Should Get a Medicare Part D Prescription Drug Plan?

A Medicare Part D Prescription Drug plan may be a good choice for you if you:

  • Don’t have creditable prescription drug coverage
  • Want to avoid paying late penalty fees if you enroll later, even if you don’t currently need prescription drugs
  • Need insurance to help you pay for your prescription drugs.

What Is a Medicare Part D Prescription Drug Plan?

A Medicare prescription drug plan is offered by private insurers who contract with the Centers for Medicare and Medicaid Services (CMS). All Medicare drug plans, whether they are provided as a stand-alone plan or as part of an all-in-one Medicare Advantage Plan, must follow CMS regulations and adhere to dollar limits for the annual deductible, the coverage gap phase, and how much you pay out-of-pocket per prescription for the catastrophic coverage phase.

Plan structure Drug plans cover a wide range of prescription drugs that people with Medicare take. Each plan’s list of drugs is called a “formulary,” and drugs are placed into different cost categories called “tiers.”
Benefits available Prescription drugs that are on your plan’s formulary. Prior authorization, quantity limits, and step therapy may apply. You must follow your plan’s rules.
Cost sharing You’re responsible for monthly premiums, annual deductible, copayments, coinsurance, and a late enrollment penalty, if applicable. You’ll have lower and limited costs if you qualify for financial assistance.

Medicare drug plans must include coverage for prescription medications including:

  • Opioids (pain medicine)
  • Vaccines
  • Insulin
  • Antibiotics

Medicare Part D coverage must include at least two drugs in each Medicare-covered drug category, unless only one drug is available. Some plans also cover anticancer drugs, such as oral chemotherapy drugs and anti-nausea drugs.

The only exception to the medications offered under medicare drug coverage through Part D are medications you don’t self-administer, such as outpatient prescription drugs like those received in the emergency room (ER).

Part D prescriptions are organized into tiers. Lower-cost tiers contain the lowest-cost drugs while the higher tiers include higher copayments and more specialty drugs. The exact type of drug in each tier will vary by plan, and the organization of tiers can differ among plans as well. In general, tiers are organized this way:

  • Tier 1: Preferred generic drugs
  • Tier 2: Nonpreferred generic drugs
  • Tier 3: Preferred brand-name drugs
  • Tier 4: Nonpreferred brand-name drugs
  • Tier 5: High-cost specialty and injectable drugs

Part D drug coverage works differently with other insurance plans, so if you have additional insurance coverage, you can check how Part D will work with your plan:

Benefits available with a Medicare Part D Drug plan

In addition to prescription drug coverage based on your plan’s rules and formulary, Part D plans must also cover free medication therapy management (MTM) for complex health needs if you meet certain requirements or are in a program to help members use their opioids safely. This program helps you and your doctor make sure that your medications are working to improve your health.

Advantages of a Medicare Part D Plan Disadvantages of a Medicare Part D Plan
  • Covers a wide variety of medications that Medicare beneficiaries typically take
  • Must follow Medicare’s regulations and out of pocket limits on what you spend on drugs
  • Widely available
  • Late penalties are imposed if you delay enrollment
  • You pay more for brand name or specialty drugs
  • Coverage gap phase

Compare your Medicare Part D Drug Plan options

The specific Medicare stand-alone drug plans and Part C Medicare Advantage Plans that are available to you will vary based on your specific situation as well as your location. Use Medicare’s online plan comparison tool to research plans, then call the specific plan provider for more details or to enroll.

You can also contact your State Health Insurance Assistance Program (SHIP) for help navigating plan comparisons or with specific questions about a Medicare drug plan or Medicare Advantage Plan.

View options for drug coverage, costs, and recommendations:

Plan type Eligibility Costs Recommendations
Stand-alone Prescription Drug Plan (PDP) Must have Medicare Part A and/or Part B, or be enrolled in a Private Fee-for-Service (PFFS) or Medical Savings Account (MSA) Advantage Plan Annual deductible, monthly premiums, copays and, coinsurance during all coverage phases Enroll in a PDP when you are first eligible to avoid late enrollment penalties unless you have creditable coverage.
Medicare Advantage Plan with Drug Coverage (MA-PD) Must have Medicare Part A and Part B Plan’s drug deductible plus monthly premiums (there are zero-premium plans available), copays, and coinsurance during all coverage phases If you want Part A, B, and D benefits bundled together, choose a preferred provider organization (PPO) or health maintenance organization (HMO) or PFFS with drug coverage.
Other creditable drug coverage, such as:

FEHB, VA, TRICARE, CHAMPVA, Indian Health Services, SSI

Must have employer/union health coverage or other group health plan that provides drug coverage that is equal to or better than Part D Plan’s drug deductible plus monthly premiums, copays, and coinsurance You may defer enrollment in a Part D plan. When your creditable prescription drug coverage ends, you will be eligible for a Special Enrollment Period (SEP).
Extra Help A yearly income of up to $19,320 and up to $14,790 in resources for an individual

A yearly income of up to $26,130 and up to $29,520 in resources for married couples

Plan premiums and deductibles depending on your income level. Copays and coinsurance: In 2022, drug costs are no more than $3.95 for each generic drug and $9.85 for each brand-name covered drug Extra Help is one way of getting help with paying for your Medicare drug costs. You must show proof that you qualify, and your plan will let you know the level of Extra Help you get. You can have Extra Help as long as you meet income and resource limits.

Who Is Eligible for a Medicare Part D Prescription Drug Plan?

You’re eligible for a stand-alone Medicare Part D Prescription Drug Plan if you are enrolled in Part A and/or Part B and are a United States citizen or lawfully present. You’re eligible for Medicare prescription drug coverage as part of a Medicare Advantage Plan (Part C) if you are enrolled in both Parts A and B. You can only enroll in a plan that is available in your area.

If you have a PPO or HMO Medicare Advantage Plan, you cannot purchase a stand-alone drug plan. You can purchase a stand-alone drug plan if you have a PFFS or MSA Medicare Advantage Plan.

How Much Does a Medicare Part D Prescription Drug Plan Cost?

Your costs include a monthly premium, annual deductible, and copays or coinsurance for prescription drugs after your deductible is met. Each plan has a list of preferred pharmacies and drugs on their formulary. Part of your comparison includes checking to see if your pharmacies and drugs are included in the plan you are considering. CMS sets the coverage gap, called the “donut hole,” amount and the maximum amount you pay in the catastrophic coverage phase.

In 2022, once you and your plan have spent $4,430 and until you spend $7,050, you are in the coverage gap. Drug deductible limits are $480 in 2022.

See how costs compare for these stand-alone Part D plans (PDPs) in Denver in 2022:

PDP Plan name Monthly premium Deductible Tiers/Initial coverage phase copay/coinsurance Gap coverage phase Catastrophic coverage phase
Humana Walmart Value RX  $22.70 $480 Preferred generic: $1

Generic: $4

Preferred brand: 16%

Nonpreferred drug: 41%

Specialty tier: 25%

Generic drugs:

25%

Brand-name drugs:

25%

Generic drugs:

$3.95 copay or 5% (whichever costs more)

Brand-name drugs:

$9.85 copay or 5% (whichever costs more)

AARP MedicareRX Saver Plus  $44.00 $480 Preferred generic: $1

Generic: $15

Preferred brand: $46

Nonpreferred drug: 40%

Specialty tier: 25%

Generic drugs:

25%

Brand-name drugs:

25%

Generic drugs:

$3.95 copay or 5% (whichever costs more)

Brand-name drugs:

$9.85 copay or 5% (whichever costs more)

Anthem Mediblue RX Standard $66.20 $430 Preferred generic: $1

Generic: $4

Preferred brand: $44

Nonpreferred drug: 34%

Specialty tier: 25%

Generic drugs:

25%

Brand-name drugs:

25%

Generic drugs:

$3.95 copay or 5% (whichever costs more)

Brand-name drugs:

$9.85 copay or 5% (whichever costs more)

How Do I Enroll in a Medicare Part D Plan?

Once you choose a Medicare drug plan, there are multiple ways to get Part D drug coverage:

  • Enroll on the Medicare Plan Finder or the plan’s website
  • Complete a paper enrollment form
  • Call the plan
  • Call us at (800) MEDICARE or (800) 633-4227. TTY: (877) 486-2048

When you join a Medicare drug plan, you’ll give your Medicare number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.

HMO: Health Maintenance Organization – Services provided by a network of providers. Primary Care Physician (PCP) and referrals to specialists required.

PPO: Preferred Provider Organization – Lowest cost services provided by a network of providers, but you can choose to receive care out of network. PCP and referrals are not required.

PFFS: Private Fee-for-Service – You choose Medicare-approved providers, and your plan pays as long as the providers agree to treat you.

MSA: Medical Savings Account – Combination of a medical savings account (funded by Medicare) and high-deductible MA Plan. Your MSA pays for Medicare-covered services, then you pay out of pocket until you reach your deductible.

SNP: Special Needs Plan – Tailored to fit the needs of certain populations, such as those with chronic conditions, those who require long-term care in a facility, and those who are dual eligible for Medicare and Medicaid due to limited resources. Specialized care, lowest costs, care coordination, and drug coverage included.

If you join a Part C Medicare Advantage Plan, you’ll usually get drug coverage through that plan. In certain types of plans that can’t offer drug coverage like MSA plans or choose not to offer drug coverage like certain PFFS plans, you can join a separate Medicare drug plan. If you’re in a HMO, HMO Point-of-Service (POS) plan, or PPO, and you join a separate drug plan, you’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

You can only join a separate Medicare drug plan without losing your current health coverage when you’re in a:

  • PFFS plan
  • MSA plan
  • Cost plan
  • Certain employer-sponsored Medicare health plans

Talk to your current plan if you have questions about what will happen to your current health coverage.

Unless you have creditable coverage, the best time to enroll in a Medicare Part D Plan is when you are first eligible during your Initial Enrollment Period (IEP). This seven-month period starts three months before the month of your 65th birthday, the month of your birthday, and ends three months after your birthday month.

Who Should Get a Medicare Part D Plan?

Medicare Part D Plans are optional, but if you have Original Medicare A and/or B, you should consider getting a Part D plan if you don’t have creditable prescription drug coverage. If you miss your initial enrollment period, or don’t take advantage of a SEP, you may pay a late enrollment penalty that will remain in effect for as long as you have a Part D plan.

If you don’t currently need prescription drugs, you can enroll in a low-premium plan available in your area so that you don’t have to incur late fees if you need prescription drugs later. Alternatively, you can join a zero-premium MA-PD plan.

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Certified Senior Advisor (CSA)®

As a health care professional since 1987, Kelly Blackwell has walked alongside and cared for seniors as they journey through the season of their fourth quarter of life. Blackwell holds a Bachelor of Science in nursing from the University of Northern Colorado, a Master of Science in health care administration from Grand Canyon University, an interprofessional graduate certificate in palliative care from the University of Colorado Anschutz Medical Campus and holds a Certified Senior Advisor® credential from the Society of Certified Senior Advisors.

Blackwell contributes to the University of Colorado-Anschutz blog and has been published in “The Human Touch” distributed by the University of Colorado Center for Bioethics and Humanities. She cowrote “Dying Is” for Pathways Hospice.

A registered nurse, Blackwell understands health insurance choices influence quality of life and are driven by values, goals, and beliefs. She’s passionate about engaging with, educating, and empowering seniors as they navigate the health care system. She’s equipped to lend an experienced, compassionate voice to beneficiaries seeking information about Medicare Advantage Plans.

As a CSA®, Blackwell has access to valuable resources for Medicare beneficiaries. Her work as a bedside nurse and clinical manager has given her the opportunity to see how Medicare rules, regulations, and benefits work when patients need them. With a passion to learn and to make a difference in the lives of seniors, Blackwell supports seniors through Medicare and fourth-quarter life decisions.

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