Find Medicare Part D Prescription Drug Plan Coverage

Fact Checked
Contributing expert: Kelly Blackwell, Certified Senior Advisor®
Updated: January 15, 2022


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Kelly Blackwell
Certified Senior Advisor (CSA)®
Kelly Blackwell
Certified Senior Advisor (CSA)®

Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.

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 standalone Part D plan that is administered by Medicare-approved private insurance companies. You must be enrolled in Medicare Part A and/or B to join a standalone Part D plan.
  • Through a Medicare Advantage (Part C) Plan or other Medicare Health plan that includes prescription drug coverage. 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 (like drug coverage from an employer or union) or get Extra Help. You can avoid paying late enrollment penalties if you need a standalone 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 Part D Prescription Drug Plan is offered by private insurers who contract with the Centers for Medicare and Medicaid Services (CMS). All Medicare Part D drug plans, whether they are provided as a standalone 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 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.

Every Medicare Part D drug plan has a formulary and must include coverage for prescription medications including:

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

The only exception to the medication coverage under Part D are medications you don’t self-administer, such as those you receive in an outpatient hospital setting like the emergency room.

Medicare 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: Non-preferred generic drugs
  • Tier 3: Preferred brand-named drugs
  • Tier 4: Non-preferred brand-named drugs
  • Tier 5: High-cost specialty and injectable drugs

Medicare Part D also 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 plan

In addition to prescription drug coverage based on your plan’s rules and formulary, each Medicare Part D plan must offer 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 for 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 Prescription Drug Plan options

The specific Medicare standalone drug plans and 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
Standalone Prescription Drug Plan (PDP) Must have Medicare Part A and/or Part B, or be enrolled in a PFFS or 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 PPO or HMO or PFFS with drug coverage.
Other creditable drug coverage, such as:

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

Must have employer/union 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 coverage ends, you will be eligible for a Special Enrollment Period.
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, $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 standalone Medicare Part D Prescription Drug Plan if you are enrolled in Part A and/or Part B, and you are a U.S. citizen or lawfully present. You’re eligible for Part D 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 standalone drug plan. You can purchase a standalone 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 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 standalone Part D plans (PDPs) in Denver, CO 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%

Non-preferred 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

Non-preferred 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

Non-preferred 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 prescription drug coverage:

  • Enroll on the Medicare Plan Finder or on the plan’s website.
  • Complete a paper enrollment form.
  • Call the plan.
  • Call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.

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.

If you join a Medicare Advantage Plan, you’ll usually get drug coverage through that plan. In certain types of plans that can’t offer drug coverage (like Medical Savings Account plans) or choose not to offer drug coverage (like certain Private Fee-for-Service plans), you can join a separate Medicare drug plan. If you’re in a Health Maintenance Organization, HMO Point-of-Service plan, or Preferred Provider Organization, 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:

  • Private Fee-for-Service Plan
  • Medical Savings Account 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 Open Enrollment Period: 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 drug coverage. If you miss your initial enrollment, or don’t take advantage of a Special Enrollment Period, 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 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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