Medicare Part D

Medicare Part D is available to anyone who qualifies for Original Medicare. 

Purchasing a standalone Part D plan or receiving one through a Medicare Advantage plan from a private insurance company is the only way to receive this prescription drug benefit.

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”

How Medicare Part D works

Each Part D plan must meet a certain standard of coverage set by Medicare. Plans have a list of prescription drugs they cover (called a formulary) and place drugs into different “tiers” on these formularies.

The formulary includes at least two drugs in the most commonly prescribed categories and classes.

The formulary might not include the specific drug you are used to taking. However, in most cases, a similar one should be available. If you or your doctor believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.

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.

In some cases, if your drug is in a more expensive tier and your doctor 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.

How to use your Part D card

When you have to use your Part D card in person, you’ll need your red, white, and blue Medicare card, your photo ID, and your Part D membership card.

Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. Now, to avoid waste or unwanted costs, plans have to get your approval to deliver a prescription (new or refill) unless you ask for the refill or request the new prescription. Some plans may ask you for your approval every year so that they can send you all new prescriptions without asking you before each delivery. Other plans may ask you before each delivery.

Network pharmacies

Medicare drug plans have contracts with network pharmacies. These pharmacies have agreed to provide members of Part D plans a discounted price. In some Part D plans, your prescriptions are only covered if you get them filled at network pharmacies.

Along with retail pharmacies, your plan’s network might include preferred pharmacies, a mail-order program, or an option for retail pharmacies to supply a 2- or 3-month supply.

  • Preferred pharmacies: You may save money on your out-of-pocket prescription drug costs at a preferred pharmacy because it has agreed with your plan to charge less.
  • Mail-order programs: Get up to a 3-month supply of your covered prescription drugs sent directly to your home. 

2- or 3-month retail pharmacy programs: Participating retail pharmacies that offer a 2- or 3-month supply of covered prescription drugs.

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