Prescription Drug Plan
Drug coverage (Part D)
How to get prescription drug coverage
If you decide not to get Medicare drug coverage when you’re first eligible, you’ll likely pay a late enrollment penalty if you join later, unless one of these applies:
- You have other creditable prescription drug coverage
- You get Extra Help
Generally, you’ll pay this penalty for as long as you have Medicare prescription drug coverage.
To get Medicare drug coverage, you must join a Medicare plan that offers prescription drug coverage. Each plan can vary in cost and drugs covered.
2 ways to get prescription drug coverage
- Medicare Prescription Drug Plan (Part D) . These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
- Medicare Advantage Plan (Part C) like an HMO or PPO) or other Medicare health plan that offers Medicare prescription drug coverage. You get all of your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You must have Part A and Part B to join a Medicare Advantage Plan.
How to join a drug plan
Once you choose a Medicare drug plan, here’s how 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).
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.
Consider all your drug coverage choices
Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs (VA), the Indian Health Service, or a Medicare Supplement Insurance (Medigap) policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options.
If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you make any changes to your current coverage.
Joining a Medicare drug plan may affect your Medicare Advantage Plan
Generally, you need to join a Medicare Advantage Plan that includes drug coverage. If you join a separate Medicare Prescription Drug Plan (Part D), in most cases you’ll lose your current Medicare Advantage Plan (Part C) and go back to Original Medicare for your health coverage.
You can only join a separate Medicare Prescription 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.
What Medicare Part D drug plans cover
Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.
- List of covered prescription drugs (formulary)
Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.
The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.
A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.
Plans offering Medicare prescription drug coverage under Part D may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards.
For other changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:
- Give you written notice at least 30 days before the date the change becomes effective.
- At the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change.
Note For 2019 and beyond, drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re taking these drugs, you’ll get information about the specific changes made to generic drug coverage afterwards.
You may need to change the drug you use or pay more for it. You can also ask for an exception. Generally, using drugs on your plan’s formulary will save you money. If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generic drugs instead of brand-name drugs may save you money.
- Generic drugs
The Food and Drug Administration (FDA) says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:
- dosage form
- safety
- strength
- route of administration
- quality
- performance characteristics
- intended use
Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber about your generic drug coverage.
- Tiers
To lower costs, many plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
Here’s an example of a Medicare drug plan’s tiers (your plan’s tiers may be different):
- Tier 1—lowest copayment : most generic prescription drugs
- Tier 2—medium copayment: preferred, brand-name prescription drugs
- Tier 3—higher copayment: non-preferred, brand-name prescription drugs
- Specialty tier—highest copayment: very high cost prescription drugs
In some cases, if your drug is in a higher (more expensive) tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment.
Remember, this is only an example—your drug plan’s tiers may be different.
Costs for Medicare drug coverage
- Premium
- Yearly deductible
- Copayments or coinsurance
- Costs in the coverage gap
- Costs if you get Extra Help
- Costs if you pay a late enrollment penalty
Your actual drug plan costs will vary depending on:
- The drugs you use
- The plan you choose
- Whether you go to a pharmacy in your plan’s network
- Whether the drugs you use are on your plan’s formulary
- Whether you get Extra Help paying your Medicare Part D costs
Look for specific Medicare drug plan costs, and then call the plans you’re interested in to get more details.
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If your drug costs are higher than what you paid last year, talk to your doctor. There may be lower cost drugs you can use instead. This could save you in out-of-pocket costs throughout the year. If you want more information on drug prices, you can look at dashboards that highlight which manufacturers have been increasing their prices and also show other year-to-year drug price information. These are general or total prices and increases may not match changes in what you’ll pay. |
If you have limited income and resources, your state may help you pay for Part A and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.
How Part D works with other insurance
Employer or union health coverage refers to health coverage from your, your spouse’s, or other family member’s current or former employer or union. If you have prescription drug coverage based on your current or previous employment, your employer or union will notify you annually about whether your prescription drug coverage is creditable. Keep the information you get from them for future reference.
Call your benefits administrator for more information before making any changes to your coverage.
Note If you join a Medicare Prescription Drug Plan, you, your spouse, or your dependents may lose your employer or union health coverage.
- COBRA
There may be reasons why you should take Medicare Part B instead of, or in addition to, COBRA. If you take COBRA and it includes creditable prescription drug coverage, you’ll have a special enrollment period to join a Medicare Prescription Drug Plan without a penalty when COBRA ends.
- Medicare Supplement Insurance (Medigap) policy with prescription drug coverage
It may be to your advantage to join a Medicare Prescription Drug Plan because most Medigap drug coverage isn’t credible. You may pay more if you join a drug plan later.
Medigap policies can no longer be sold with prescription drug coverage, but if you have drug coverage under a current Medigap policy, you can keep it. If you join a Medicare drug plan, your Medigap insurance company must remove the prescription drug coverage under your Medigap policy and adjust your premiums. Call your Medigap insurance company for more information.
- Medicaid
Your drug costs are covered by Medicare. You’ll need to join a Medicare Prescription Drug Plan for Medicare to pay for your drugs.
In most cases, you’ll pay a small amount for your covered drugs. If you have full coverage from Medicaid and live in a nursing home, you pay nothing for covered prescription drugs.
If you have full coverage from Medicaid and live in an assisted living or adult living facility, or a residential home, you’ll pay a small copayment for each drug.
If you don’t join a drug plan, Medicare will enroll you in one to make sure you don’t miss a day of coverage. If you decide you want another plan, you can switch to another plan at any time.
- Supplemental Security Income Benefits
If you get benefits or help from your state Medicaid program paying your Medicare premiums, you need to join a Medicare Prescription Drug Plan for Medicare to cover your drugs. You automatically qualify for Extra Help with your prescription drug costs. If you don’t join a plan, Medicare will enroll you in one to make sure you don’t miss a day of coverage.
- State Pharmaceutical Assistance Program
Each state decides how its State Pharmaceutical Assistance Program (SPAP) works with Medicare prescription drug coverage. Some states give extra coverage when you join a Medicare Prescription Drug Plan. Some states have a separate state program that helps with prescriptions. Contact your SPAP to get more information.
- Long-term care facility
Long-term care pharmacies contract with Medicare Prescription Drug Plans to provide drug coverage to their residents. If you’re entering, living in, or leaving a nursing home, you’ll have the opportunity to choose or switch your Medicare drug plan. This allows you to choose a plan that contracts with your nursing home’s pharmacy.
- HUD housing assistance
If you get housing assistance from the Department of Housing and Urban Development (HUD), you may want to join a Medicare Prescription Drug Plan.
If you qualify for Extra Help, you won’t lose your housing assistance. However, your housing assistance may be reduced as your prescription drug spending decreases. The value of the Extra Help paying your drug costs will make up for any decrease in your housing assistance.- Food stamps
If you get food stamps, you may want to join a Medicare Prescription Drug Plan. If you qualify for Extra Help, your food stamp benefits may decline, but that decline will be offset by Extra Help.
If you’re near the food stamps eligibility cutoff, you may lose your minimum food stamp benefits because you’ll be paying less for your prescription drugs. The value of the Extra Help paying your drug costs will make up for any decrease in food stamp benefits.
- Health Insurance Marketplace
A service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.
The Health Insurance Marketplace (also known as the “Marketplace” or “exchange”) provides health plan shopping and enrollment services through websites, call centers, and in-person help.
The types of insurance listed below are all considered creditable prescription drug coverage. If you have one of these types of insurance, in most cases, it will be to your advantage to keep your current coverage.
- Federal Employee Health Benefits (FEHB) Program
The Federal Employee Health Benefits (FEHB) Program plans usually include prescription drug coverage, so you don’t need to join a Medicare drug plan. However, if you decide to join a Medicare drug plan, you can keep your FEHB plan, and your plan will let you know who pays first.
For more information, contact the U.S. Office of Personnel Management (OPM). You can also call your plan if you have questions.
- Veterans’ Benefits
You may be able to get prescription drug coverage through the Veterans Affairs (VA) program. You may join a Medicare Prescription Drug Plan, but if you do, you can’t use both types of coverage for the same prescription at the same time. For more information, contact the VA.
- TRICARE (military health benefits)
Most people with TRICARE who are entitled to Medicare Part A must have Medicare Part B to keep TRICARE prescription drug benefits. If you have TRICARE, you don’t need to join a Medicare Prescription Drug Plan.
For active-duty military enrolled in Medicare, TRICARE pays first. For inactive-duty military, your Medicare Prescription Drug Plan pays first.
If you join a Medicare Advantage Prescription Drug (MA-PD) Plan with drug coverage, the plan and TRICARE may coordinate their benefits if your MA plan network pharmacy is also a TRICARE network pharmacy. For more information, contact the TRICARE Pharmacy Program.
- Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
CHAMPVA is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. You may join a Medicare Prescription Drug Plan, but if you do, you won’t be able to use the Meds by Mail program, which can give your maintenance medications at no charge to you (no premiums, no deductibles and no co-payments). For more information, visit va.gov/communitycare/programs/dependents/champva/ or call CHAMPVA at 800-733-8387.
- Indian Health Services
Many Indian health facilities participate in the Medicare prescription drug program. If you get prescription drugs through an Indian health facility, you’ll continue to get drugs at no cost to you, and your coverage won’t be interrupted.
Joining a Medicare Prescription Drug Plan may help your Indian health facility because the drug plan pays the Indian health facility for the cost of your prescriptions. Talk to your local Indian health benefits coordinator who can tell you how Medicare works with the Indian health care system.
Note If you’re getting care through an IHS or tribal health facility or program without being charged, you can continue to do so for some or all of your care. Getting Medicare doesn’t affect your ability to get services through the IHS and tribal health facilities.
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Keep any creditable prescription drug coverage information you get from your plan. You may need it if you decide to join a Medicare drug plan later. Don’t send creditable coverage letters/certificates to Medicare. |