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Prescription Drugs

Prescription Drug Plans - Medicare Part D

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What is Medicare Part D?

Medicare Part D, also called Medicare prescription drug coverage, is optional coverage to help Medicare beneficiaries pay for prescription drugs.  The Medicare Part D plans can cover most of the prescription drugs that people with Medicare take.

Part D is optional and provided through private insurance companies approved by the federal government.

How to Get Medicare Prescription Drug Coverage

Medicare drug coverage (Part D) helps pay for prescription drugs you need.  Although it is optional, generally it is offered to anyone with Medicare.  You should consider getting Medicare drug coverage even if you don’t take prescription drugs currently.   The reason for this consideration is that you may have to pay a late enrollment penalty when joining a plan later if you decide not to get it when you’re first eligible. 


Generally, it is important to join a Medicare-approved plan that offers drug coverage to get Medicare drug coverage.   Also consider that each plan may vary in cost and specific drugs covered.

There are (2) main ways to get Medicare drug coverage:

1. Medicare drug plan.  Generally, these plans add drug coverage to the following: (Original Medicare, some Medicare Cost Plans, some Private Fee-for-Service plans, and Medical Savings Account plans).  When considering joining a separate Medicare drug plan, generally you must have Medicare Part A (Hospital Insurance) and/or Medicare part B (Medical Insurance).

2. Medicare Advantage Plan (Part C) or other Medicare health plan with drug coverage.  Generally, these plans can provide all of your Part A, Part B and drug coverage.  Generally, to join a Medicare Advantage Plan you must have both Part A and Part B.  Not all these plans offer drug coverage.

What Medicare Part D drug plans cover

Many prescription drugs that people take with Medicare generally must be covered in all plans.  Covered drugs found in a plan’s list is referred to as a “formulary”, each plan has its own formulary.   Drugs are generally placed into different levels, referred to as “tiers”, found on the Medicare Drug plan coverage “formulary”.

Each tier basically represents a different cost for drugs.  A drug found in a lower tier will generally cost less than one found in a higher tier.

In a situation where your drug is in a higher tier and your prescriber (Doctor for example) thinks that you need that drug rather than a similar drug in a lower tier, the prescriber can ask for an Exception.  The Exception may help to attain a lower coinsurance (or copayment) for the drug found in the higher tier.

Generally, Medicare drug plans and Medicare Advantage plans with prescription drug coverage will have their own formularies that list what drugs are covered.  Both brand-name prescription drugs and generic drugs are usually covered in the drug plan.   

Formularies generally include (2) or more drugs found in commonly prescribed classes and categories.  By doing this, people with different medical conditions may have more opportunity to get the prescription drugs they need.  The (2) drugs per drug category condition is something generally all Medicare drug plans must cover.  However, plans can decide which of the drugs in Part D they will offer. 

In a situation where your specific drug is not found on a formulary, in many cases a similar drug should be available.  

During the year, changes to the drug list can be made by the Medicare Drug plan if guidelines set by Medicare are followed.  Reasons for the change may include: a change in drug therapy, new available drugs or new medical information is presented.    

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