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Medicare Part D plans allow you to add prescription drug coverage to your Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. benefits or to a Medicare Advantage plan.
Medicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... (PDPs) are organized by state. The easiest way to shop and compare 2023 plans where you live is to enter your zip code in the search tool above. You can also browse by state using the links below.
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If you’re new to Medicare or simply want to learn more about 2022 Medicare prescription drug plans, you’re in the right place. This page covers a broad range of topics that will help you learn everything you need to know about Medicare’s private prescription drug plan option, Medicare Part D.
Let’s start at the beginning.
What are Medicare Part D Plans?
Original Medicare – that’s your Medicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. hospital insurance and Medicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. medical insurance – does not cover prescription medications. In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act added Part C and Part D, allowing private insurers to offer health plans (Part C) and prescription drug plans (Part D).
Medicare prescription drug plans (PDPs) are allowed to have different costs and different drug coverage. They are not all the same, so it’s critical that you make sure your prescriptions are covered at a favorable price.
You can get your Part D coverage in two different ways. The first way is to enroll in the PDP of your choice. The monthly cost of most PDPs is modest, and they work with your Original Medicare.
You can also get Part D as part of a Medicare Advantage Plan (Part C). These are private health plans that let you get all of your health care coverage from the same insurance company. Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). that have Part D drug coverage are sometimes referred to as MAPDs.
Who Qualifies For Medicare Part D?
If you have or are eligible for Medicare now, you can enroll in one of the Medicare Part D plans available in your state during a qualifying enrollment period. This includes people ages 65 and older who are U.S. citizens or permanent residents, as well as people who qualify for Medicare through their Social Security disability status.
Part D plan enrollment is 100% voluntary. In most cases, you will pay an additional monthly premium for prescription coverage. If you already have coverage, you can wait to join a PDP, but do your homework. If the prescription drug coverage you have now is not as good as Medicare Plan D coverage (Creditable coverage refers to health insurance or prescription drug benefits that meet Medicare's minimum qualifications necessary to avoid a penalty.) you may have to pay Medicare’s penalty if you join a Part D plan later.
Before you can enroll in a Medicare Prescription Drug Plan or a Medicare Advantage Plan, you will need to have both Medicare Part A and Part B. Plus, you must reside in the service area of the plan you want to join. Plans are regional, not nationwide.
When Can I Enroll In a Medicare Part D Plan?
You can enroll in a Medicare Part D Plan as soon as you are first eligible. You have a period of 7 months called your The Initial Enrollment Period is a seven-month period when new beneficiaries can enroll in Medicare without a penalty. Most people enroll in Medicare at age 65. (IEP). Your IEP starts three months before the month you turn 65 and ends three months after your 65th birth month. So, if you turn age 65 in November, your IEP starts in August and ends in February.
If you have Medicare due to a disability the timing is a little different. In this case, you can enroll in a PDP three months before and three months after your 25th month of disability payments from Social Security.
There is also an The Annual Enrollment Period is when Medicare beneficiaries can join, drop or change Medicare Advantage and Medicare Part D prescription drug plans. AEP begins on 15 October and ends on 7 December. (AEP) for Medicare Advantage and Medicare Part D, which starts on October 15 and runs through December 7. These dates are not affected by Obamacare. When you join or switch plans during AEP, your coverage begins on January 1 of the following year.
Please note that if you qualify for the Social Security Extra Help program you can enroll in a Part D Plan anytime. You don’t have to wait until In health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions..
How Much Does Medicare Part D Cost?
Every Medicare Part D Plan (PDP) is different. Provided by independent insurance carriers, PDPs have different drug formularies, A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., co-payments, and Coinsurance is a percentage of the total you are required to pay for a medical service. . Let’s start with the A formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered..
Most people are surprised to learn that Medicare drug plans are not required to cover all Medicare-approved medications. This is one of the reasons that shopping for a plan can be challenging.
Drug Plan Formularies
Every drug plan has a unique list of medications called a formulary. The formulary is simply a list of covered medications and pricing tiers. Plans create their formulary using the guidelines set by the United States Pharmacopoeia.
The formulary system makes choosing a plan challenging because it forces you to compare the medications you use across all plan formularies. If your medication is covered by a plan, it may be in a different tier than other plans and have a different A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service. or coinsurance amounts. This is why checking the exact costs of all of your medications is critical.
As if the drug formulary and tier system aren’t complicated enough, it’s nowhere near as confusing as Medicare Part D’s cost structure. Unlike other forms of health insurance, Medicare Part D has multiple phases. So, to understand what you’ll pay for your medications, you need to understand more about the Medicare Part D cost periods.
All Medicare Part D plans have a monthly premium. The average nationwide monthly premium is around $31.50. However, in most states plans start at less than $20. So, if you don’t have regular prescriptions or your prescriptions are few and common, your cost will be minimal.
Your monthly premium is not a cost phase. You’ll make this payment every month, regardless of the cost phase you’re in.
Your deductible is the first cost phase. This is the amount you’ll pay at the pharmacy before cost-sharing begins. Some plans have a $0 deductible, but most have a deductible, up to the 2023 limit of $505.
If you have minimal or no regular prescriptions, it’s conceivable that you will never take advantage of your plan’s cost-sharing benefit. That’s simply the nature of insurance. When you need it most, you’ll be happy to have it.
Initial Coverage Period
After you’ve met your plan’s deductible, you’ll start your initial coverage period. This is where you make a co-payment or coinsurance payment for your prescriptions at the pharmacy. How long you’re in the initial coverage period depends on the retail price of your medications and your plan’s benefits structure. With most 2023 plans, your initial coverage period ends when your drug costs reach $4,660. This is the Once you have met your yearly deductible, you will pay a copayment or coinsurance for each covered drug until you reach the initial coverage limit. You will then enter your plan’s coverage gap (aka, “donut... (ICL).
Coverage Gap Phase
If you reach the annual initial coverage limit, you enter the A period of time in which you pay higher cost-sharing for prescription drugs until you spend enough to qualify for catastrophic coverage. phase, also known as the doughnut hole. While you’re in the coverage gap there is no cost-sharing. You pay all costs for your prescriptions. However, you do get discounts that help lower the cost of your medications.
In 2023, you get a 75 percent discount on most brand-name drugs, paid for by the manufacturer and the federal government. The remaining 25 percent is what you pay. You also get a 25% discount on all A generic drug is a prescription medication that has the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs..
Catastrophic Coverage Phase
In 2023, catastrophic coverage begins after you have paid $7,400 in true Out-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments.. This full retail cost of your medications.
In this phase, you pay significantly less for your covered medications for the remainder of the year. The costs that help you reach the catastrophic coverage phase include:
- Your deductible;
- What you paid during the initial coverage period;
- Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap;
- Amounts paid by others, including family members, most charities, and other persons on your behalf; and
- Amounts paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service.
Costs that do not help you reach catastrophic coverage include monthly premiums, the cost of non-covered drugs, the cost of covered drugs from pharmacies outside your plan’s network, and the 75% generic discount.
Beneficiaries will pay $4.15 for those generic or preferred multisource drugs with a retail price under $83 and 5% for those with a retail price greater than $83. For brand-name drugs, beneficiaries will be charged $10.35 for those drugs with a retail price under $207 and 5% for those with a retail price over $207.
Note: If you get Extra Help from Social Security, the coverage gap phase will not apply to you. Instead, you’ll pay different costs during the year.
Are Prescription Drug Discounts Available?
A Part D Plan does not cover everything, and it’s only good for up to $4,660 of initial benefits (2023 initial coverage limit). After that, you pay out of pocket until you become eligible for catastrophic coverage. This is why we highly recommend GoodRx for People on Medicare. They have the most innovative prescription discount program we’ve seen for people with Medicare benefits.
When Should I Get Medicare Part D?
Most people join a Medicare Part D Plan during their Initial Enrollment Period (IEP). IEP is a 7-month period that occurs when you first become eligible for Medicare. It starts three months before the month of your 65th birthday and ends three months after the month of your 65th birthday.
If you have Medicare due to a disability, your IEP for Medicare Part D starts 3 months before the 25th month of your disability and ends 3 months after your 25th month of disability.
For most people, their IEP is the best time to get Part D coverage. The one In a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... is if you have “creditable coverage” through an employer’s health plan or retirement benefit. It’s best to call Medicare to make sure the coverage you have is credible.
If you don’t enroll in Part D when you are first eligible, and you don’t have creditable coverage, Medicare will assess a late penalty on top of your Part D premium if you join a Part D plan at a later date. It’s not a one-time penalty, either. You pay it for as long as you have coverage.
Is Medicare Part D Mandatory?
Medicare Part D is not mandatory. However, unless you have other creditable coverage, it is critical that you enroll as soon as you are first eligible. If you don’t, you may have to pay a late enrollment penalty in addition to your monthly Part D premium if you decide to enroll later. The late enrollment penalty also applies if you go without Medicare prescription drug coverage (or creditable coverage) for 63 or more days. The penalty adds 1 percent to your premium for every month that you didn’t have creditable coverage.
What is The Late Enrollment Penalty (LEP)?
Unless you are exempt, Medicare will impose a penalty if you do not join a Part D plan when first eligible to do so. Those exempt from the penalty include people who:
- Had creditable coverage, or
- Qualify for the Social Security's Low-Income Subsidy (LIS) program helps Medicare beneficiaries pay for their Medicare Part D prescription drugs by paying some of the costs. Also known as "Extra Help", beneficiaries who qualify for LIS receive premium... (LIS), or
- Were eligible for a Special Enrollment Periods (SEPs) allow beneficiaries to change their Medicare Advantage and Part D plans due to a special circumstance. Common reasons for a SEP include moving, losing employer coverage, and Medicaid eligibility, to name....
The penalty is 1% of the national base monthly premium for every full month the individual could have been but was not enrolled. The base calculation changes annually and is based on the average national base premium.
The lifetime penalty is added to the person’s monthly premium that is collected by the Part D plan, not directly by CMS. If a penalty is imposed before the A person who has health care insurance through the Medicare or Medicaid programs. is 65, it is removed when he or she turns 65.
If the late enrollment penalty was imposed in error, there is a process to request reconsideration. Medicare uses Maximus, an independent review organization, to process reconsiderations. The process can take months, and the decision is final.
Note: The late enrollment penalty must be paid during the time the penalty is being reconsidered. On approval, the beneficiary will be reimbursed for all erroneous penalty charges.
What If I Don’t Take Prescription Medications?
Prescription drug coverage is a smart choice for all Medicare beneficiaries. Even though you may not take medications now, you never know when you will need them. If you don’t currently have prescriptions, choose one of the low-cost basic plans. You can always upgrade next year if your medical needs change. Also, don’t forget that enrolling in a Part D plan when you are first eligible will save you a lot of money down the road.
What If I Already Have A Creditable Prescription Drug Plan?
If you currently have prescription drug coverage from an employer or union, call your employer or union’s benefits administrator prior to making changes to your plan. Your employer or union plan will tell you each year if your prescription drug coverage is creditable prescription drug coverage.
In most cases, when you drop your employer or union coverage, you will not have the option to get it back. Plus, most employer or union drug coverage plans cannot be dropped if you have other health care coverage (e.g., doctor and hospital) through their group plan. Be aware that if you drop coverage for yourself, you will not be able to keep coverage for your spouse and dependents.
When Does Part D Coverage Begin?
If you join a plan during your IEP prior to the month of your 65th birthday, your prescription coverage starts on the first day of your birthday month. If you join during or after your birth month, your coverage starts on the first day of the next month. It works the same way if you have Medicare for a disability. The key month is the month you receive your 25th SSDI payment.
When Is The Medicare Part D Plan Annual Election Period?
If you missed your IEP, or if you have a Part D Plan and want to change it, mark the Annual Election Period (AEP) on your calendar. This is the one time each year that all Medicare beneficiaries can join, drop, or switch plans.
AEP is at the same time each year. It starts on October 15 and ends on December 7. Be aware that coverage does not start immediately. Regardless of the day you join, your coverage begins on January 1 and continues for the entire year.
There are some instances where you may be given a Special Enrollment Period (SEP) to enroll or change plans. One of the most common reasons for a SEP is moving out of a plan’s service area. If believe you have a special circumstance that warrants a SEP, call Medicare you are eligible for a SEP, call 1-800-MEDICARE, and explain your situation.
There is one additional enrollment period that may apply to you. It’s the Medicare Advantage During the Medicare Open Enrollment Period, Medicare Advantage and Part D plan members can change, switch, or drop a plan they chose during the Annual Election Period. OEP starts on January 1 and ends on March 31. (MAOEP). This is a new enrollment period that takes place every year from January 1 to March 31. It sounds a lot like AEP, but it is not the same. MAOEP only applies if you are currently enrolled in a Medicare Advantage or Medicare Part D plan.
If you’re enrolled in a Medicare Advantage plan, during MAOEP you can switch to a different Medicare Advantage plan or switch to Original Medicare and join a Medicare Part D drug plan. You can only switch plans once during this period.
How Do I Get Enrolled?
You must affirmatively enroll in a Part D plan to participate; It’s not automatic. If you are eligible and don’t enroll during the Annual Enrollment Period (or your Initial Enrollment Period if you are just turning 65) you will have to pay a late enrollment penalty (LEP) to use the benefit. The penalty is about 1% of the average premium times the number of months that you were eligible but not enrolled.
Where Do I Enroll?
You must enroll in a Part D plan through an authorized health insurance agent, through the plan itself, or through the Medicare.gov website. The first step is to compare plans.
Can I switch my Medicare Part D Plan?
If your Medicare Part D Plan does not meet your needs, you can and should switch plans. The most common reason people switch from one plan to another is that their medications change. However, you might also discover that a plan that was a great deal last year is not such a good deal this year.
Before you do anything, you need to know your options. In most cases, you can’t simply switch from one plan to another, except during the Medicare Annual Election Period (AEP). If your plan does not meet your needs, you need to take the time to educate yourself about your current plan and other plans so you can make an informed decision. That way, when AEP comes around, you can review the new plans, and changes to your preferred plans, before making a final decision. It all comes down to the numbers.
Is there a penalty for switching Part D Plans?
You cannot be penalized for switching plans. However, you can be penalized if you do not enroll in a Part D plan when first eligible. That said, you can only switch plans once a year, during the Annual Election Period.
When can I switch my Part D Plan?
The Annual Election Period is the best time to switch plans. It starts on October 15 and ends on December 7. In some cases, you may qualify for a Special Enrollment Period. A SEP may be available to you if you move out of your plan’s service area (call 1-800-MEDICARE to inquire). Also, if you enrolled in a Medicare Advantage plan, and then later change your mind, you can switch plans or go back to Original Medicare and join a Part D plan during the Medicare Advantage Open Enrollment Period. This enrollment period runs from January 1 to March 31.
Can Changing My Medicare Part D Plan Lower My Drug Costs?
Medicare.gov suggests six ways to reduce the cost of prescription drugs. They include:
- Switching to generics or other lower-cost drugs;
- Choosing a plan (Part D) that offers additional coverage in the gap (donut hole);
- Pharmaceutical Assistance Programs;
- State Pharmaceutical Assistance Programs;
- Applying for Extra Help; and
- Exploring national and community-based charitable programs.
We suggest a 7th method: compare plans annually and switch to the best plan for your health and financial needs. It’s not just about gap coverage, because most beneficiaries never reach the coverage gap. What you need is the best overall plan for you, and it may change every year.
Medicare Part D Plans (PDPs) help you pay for your prescription drugs. All PDPs are different, and the costs can vary significantly. It’s not uncommon for a prescription under one plan to cost you $5 at the pharmacy, while the very same prescription through another plan costs $25. This is why carefully comparing and choosing your Part D Plan annually is so crucial. You need to choose the best plan for you, which includes covered medications, the monthly premium, and the costs for your prescriptions (copay).
Can I Get Extra Help Paying For Prescription Drug Coverage?
People with limited income and resources may qualify for Extra Help paying their Medicare prescription drug coverage costs. Extra Help is a Medicare program to help people with limited income and resources pay Medicare prescription drug costs. You may qualify for Extra Help, also called the low-income subsidy, if your yearly income and resources are below the established limits. Call 1-800-MEDICARE.
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