Prescription Drugs (Part D)

To enroll in a Part D plan, you must meet these criteria:

Certain individuals may qualify for a Special Enrollment Period to join or switch Part D plans under specific circumstances.

If you're enrolled in Medicaid and become eligible for Medicare Part D, you will likely be automatically enrolled in a plan, with minimal or no premium costs.

It's generally wise to consider enrolling in a Part D plan during your initial Medicare enrollment period to avoid potential late penalties. You should especially consider a Part D plan if:

Part D plans typically consist of four stages: the deductible, initial coverage, coverage gap (or "donut hole"), and catastrophic coverage.

Each Part D plan has a formulary that lists covered medications, which are grouped into cost tiers. Lower-tier medications, often generic, are more affordable, while higher-tier, brand-name drugs may come with higher out-of-pocket costs. Formularies are updated annually and can change throughout the year based on new drug availability or FDA updates. Always review your plan's formulary to ensure your medications are covered.

Original Medicare does not cover over-the-counter medications. While some Part D plans might provide limited OTC drug coverage, for broader coverage of OTC products, a Medicare Advantage plan that includes this benefit is often a better option. These plans sometimes offer prepaid cards to purchase eligible OTC products.

Medications excluded from Part D coverage typically include:

However, if a medication typically excluded is prescribed for an approved medical condition, it may still be covered.

If you don't enroll in a Part D plan or have other creditable drug coverage when you're first eligible, you may face a penalty. The penalty is 1% of the national base beneficiary premium for each month you delay enrollment.

Exceptions to the penalty apply if you have other creditable coverage, qualify for financial assistance, or can provide proof that you were not properly informed about your coverage options.

If you're having trouble affording your medications, you may qualify for financial assistance through the Low-Income Subsidy (LIS) program. This program can help reduce your prescription drug costs significantly.

You can also save on medications by using mail-order pharmacies, opting for generic alternatives, or using prescription discount cards. Many pharmacies also offer rewards programs that include prescription discounts. Additionally, purchasing a 90-day supply of medications, when available, can save money and reduce trips to the pharmacy.

If you have more than one type of insurance, such as retiree or group health coverage, you’ll need to coordinate benefits to maximize savings. Part D may be your primary or secondary payer, depending on the circumstances.

For example, if you have retiree coverage, Part D is usually the primary payer. If you have employer coverage and are still working, your employer's plan is the primary payer, with Part D as the secondary payer.

You can enroll in Part D coverage during specific times of the year:

If a 5-star Part D or Medicare Advantage plan becomes available in your area, you may switch to that plan at any time from December 8 to November 30 of the following year. This rating is based on plan performance and member satisfaction.