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WHAT IS MEDICARE PART D?
Medicare Part D is a government-run program that provides prescription drug coverage. You can enroll in a standalone Part D plan or choose a Medicare Advantage plan that includes prescription drug coverage.
Original Medicare (Parts A and B) does not cover prescription drugs. To get prescription drug coverage, you must enroll in a Part D plan or a Medicare Advantage plan with prescription drug coverage (MAPD plan).
Part D plans require a monthly premium and have additional costs, such as deductibles, copayments, and coinsurance. You'll receive a separate Part D insurance card to use when filling prescriptions.
Medicare Part D plans cover a wide range of prescription drugs, including medications for immunosuppression, cancer, mental health conditions, and HIV/AIDS. However, the specific drugs covered may vary by plan and provider.
Part D plans can be used as standalone plans with Original Medicare or as part of a Medicare Advantage plan.
Medicare Part D plans often categorize drugs into "tiers," with each tier having different cost-sharing requirements. Generally, lower-tier drugs have lower costs than higher-tier drugs.
These are the 5 tiers:
Tier 1: Lowest co-payment plan, Mostly Preferred Generic Drugs
Tier 2: Lowest co-payment, Non-Preferred Generic Drugs
Tier 3: Medium co-payment, Preferred Brand-Name Prescription Drugs
Tier 4: Higher co-payment, Non-Preferred Brand-Name Drugs
Tier 5: Highest co-payment, Very High Cost Specialty Prescription Drugs
How Does Medicare Part D Work
How to Enroll in Medicare Part D
To avoid late-enrollment penalties, it's important to enroll in a Medicare Part D plan as soon as you're eligible, whether that's when you turn 65 or lose other health coverage.
You must be enrolled in both Medicare Parts A and B to enroll in a Part D plan or a Medicare Advantage plan with prescription drug coverage. The best time to enroll is during your Initial Enrollment Period, a 7-month window around your 65th birthday.
Choosing a Part D plan can be complex. To simplify the process, we at Topflight Insurance can help you compare plans and find the best option for your needs. We'll consider your current medications and preferred pharmacies to identify the plan that offers the lowest overall cost.
Each Medicare Part D plan has a formulary, which is a list of covered drugs. Federal regulations require plans to cover at least two drugs in each category. All plans must cover medications used for:
Antidepressants
Antipsychotics
Anticonvulsants
Anti-cancer
Immunosuppressants
HIV/AIDS
Part D plans must also cover vaccines used to prevent illnesses unless those vaccines already fall under Part B coverage.
What Drugs Are Not Covered by Part D?
What Drugs Are Not Covered by Part D?
Some medications are covered by Medicare Part B instead of Part D. This includes medications that are administered by a healthcare provider, such as intravenous drugs.
Part D does not cover over-the-counter (OTC) medications like ibuprofen or Tylenol. Other medications not covered by Part D include:
Any weight loss or weight gain drugs
Fertility medication
Erectile dysfunction medications
Hair loss prevention drugs
Other cosmetic medications
While some plans may offer limited coverage for certain non-covered medications, this is not the norm.
If your prescription isn't covered by your plan, you can request an exception from your insurance company. Your doctor will need to provide documentation supporting the need for the medication.
Some plans may require step therapy, where you try a less expensive medication before being approved for a more expensive one.
If your plan doesn't cover your prescription, you can explore prescription discount programs like GoodRx, Cost Plus Drugs, Blink Health, SingleCare, or Optum Perks. These programs can help you save money on prescription costs.
Frequently Asked Questions
New to Medicare?
What is Medicare and How Do I Qualify?
Medicare Advantage plans are offered by private insurance companies contracted through Medicare as an alternative to Original Medicare. These plans combine all of the benefits of Medicare Part A (hospital) and Part B (medical), and may also include prescription drug coverage, if they are Medicare Advantage Prescription Drug Plans.These plans combine all of the benefits of Medicare Part A (hospital) and Part B (medical), and may also include prescription drug coverage, dental or vision coverage all for an affordable and sometimes $0 monthly plan premium.
What is Medicare Advantage (Part C)?
Medicare Advantage plans are offered by private insurance companies contracted through Medicare as an alternative to Original Medicare. These plans combine all of the benefits of Medicare Part A (hospital) and Part B (medical), and may also include prescription drug coverage, if they are Medicare Advantage Prescription Drug Plans. These plans combine all of the benefits of Medicare Part A (hospital) and Part B (medical), and may also include prescription drug coverage, dental or vision coverage all for an affordable and sometimes $0 monthly plan premium.
What are Medicare Prescription Drug Plans (Part D)?
Medicare Part D plans add prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans. A prescription drug plan may help you save money on existing prescriptions or on medication needs in the future.
Not affiliated with the United States government or federal Medicare program. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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