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What is Medicare Prescription drug coverage?

Medicare Part D is voluntary prescription drug coverage that you can choose to add to your Original Medicare. Many Medicare Advantage plans include Part D coverage among their benefits. Under Original Medicare (with or without a Medicare Supplement/Medigap insurance policy), you will need to seek out a Part D standalone plan which you can do here through the local, licensed agent network.

While plans may vary significantly, all plans must adhere to federal guidelines and be approved yearly. For the most part, Part D plans either discount your drug cost by a set percentage or require a copay that may vary based on the drug being purchased. Your selected plan will require you to use pharmacies in their network.

Who is eligible and may enroll in a Part D prescription drug coverage?

Participation in a Part D prescription drug plan is available to nearly anyone enrolled in Medicare A and B, but it is not mandatory.

It can be a good idea to enroll in a Part D plan if:

  • You regularly take prescription drugs
  • You do not already have creditable prescription drug coverage elsewhere
  • Your health/family history leads you to believe you will need to take a prescription drug in the future
  • You are having difficulty affording your prescription drugs.

How and when to enroll?

Medicare Part D has specific enrollment periods

  • 65th Birthday

    Initial Enrollment Period (IEP)

    The 7-month period that begins 3 months before you turn age 65, includes your birthday month, and ends 3 months after the month you turn age 65.

    For those under age 65 with a qualifying disability and receiving Social Security or Railroad Retirement Board disability benefit, you will have a 7-month enrollment period. This period begins 3 months before your 25th month of receiving Social Security or Railroad Retirement Board disability benefit includes your 25th month, and ends 3 months after.

  • Oct 15 - Dec 7

    Annual Election/Enrollment Period (AEP)

    Begins October 15 and ends December 7 with coverage taking effect January 1st of the coming year.

  • Qualifying Event.

    Special Enrollment Period (SEP)

    Allows you to switch or drop a Part D plan under special circumstances. Here are some examples:

    • You returned from living outside the United States after a long-term permanent residence outside the U.S.
    • You are leaving, losing or joining an employer or union.
    • Your plan's contract with Medicare is terminating.
    • You recently involuntarily lost your creditable prescription drug plan.
    • You live in, are moving into, or recently moved out of a nursing home or long-term care facility.

    Go to for more information.

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Newly eligible for Medicare? Call us at (888) 928-1456 TTY 711 or speak with a licensed sales agent near you. Hours of Operation

What you should know about Prescription drug coverage (Part D)

  • Annual deductible

    Each year, you may be required to meet a Medicare Part D deductible, though some plans may only require a partial deductible or have a zero deductible. During the deductible phase, you will pay the discounted network price for your medications until you meet your plan’s deductible. In 2021, the deductible can be no more than $445.

  • Initial coverage

    After you’ve met your annual deductible amount tallied by your insurer, you move into initial coverage and must pay a copay for your prescription drugs based on the plan’s drug formulary. The formularies can be different from plan to plan. Under the formularies, medications are separated into Tiers. Each Tier has a copay amount for the drugs in that tier. For example, drugs in Tier 1 may have a $5 copay for generic medications, while Tier 3 has a $40 copay and represents certain brand name drugs. The insurer will continue to keep track of your spending until you and the insurance company reach the out-of-pocket limit set by Medicare for the year you are in. In 2021, the out-of-pocket limit for the initial coverage phase is $4,130.

  • Coverage gap

    After reaching your initial coverage limit for the year, you enter what is referred to as the coverage gap. During this time, you pay no more than 25% of the cost of your medication. The insurer will be keeping track of your spending until you reach the coverage gap out-of-pocket limit set by Medicare for the year you are in. In 2021, the out-of-pocket limit for the coverage gap phase is $6,550.

  • Catastrophic coverage

    At the end of the coverage gap, you will get catastrophic coverage, for which you pay a small coinsurance amount or copayment for covered drugs for the remainder of the year.

Drug utilization rules

Insurers are allowed to set certain rules to ensure safety and manage costs. Below are some common examples:

Quantity limits

Quantity limits

Quantity limits are set to control how much medication you can purchase at once or upon each refill. If your doctor prescribes outside of these limits, they will be required to file an exception form.

Prior authorization

Prior authorization

Prior authorization stipulates that your doctor must obtain approval from the plan before allowing a pharmacy to dispense certain medications.

Step therapy

Step therapy

Step therapy regulates prescribing more expensive drugs when less expensive alternative may be as effective. You may be required to try similar, lower cost drugs before the plan will cover the prescribed drug. If the alternative works, both you and the insurer save money.

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