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Medicare Prescription Drug Coverage



Medicare Prescription Drug Coverage or also known as Medicare Part D is an optional benefit. It is offered to everyone with Medicare. 

In order to get Medicare prescription drug coverage, you must first join a plan approved by Medicare and offers drug coverage. 

2 ways to get Medicare prescription drug coverage:
  1. Medicare Prescription Drug Plans. These plans, sometimes call "PDPs" add drug coverage to Original Medicare, some Medicare Cost Plans, Medicare Private Fee-for-Service Plans, and Medicare Medical Saving Account plans. You must have Part A and/or Part B to join this plan.
  2. Medicare Advantage Plans (other Medicare health plans that offer Medicare prescription drug coverage). You get all your Part A, Part B, and 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 this plan.
In either case, you must live in the service area of the Medicare drug plan you want to join. Both types of plans are called Medicare drug plans. 

IMPORTANT: If you have employer or union coverage

Call your benefits administrator before you make any changes or sign up for any other coverage. Signing up could cause you to lose your employer or union health and drug coverage. If you lose your employer or union coverage, you may not be able to get it back. 

When can I join, switch or drop a Medicare Drug Plan?
  • When you first become eligible for Medicare. You can join during your Initial Enrollment Period.
  • If you get Part A and Part B for the first time during the General Enrollment Period.
  • Between October 15 - December 7 each year. Changes will take effect on January 1 of the following year, as long as the plan gets your request before December 7. 
  • If you're enrolled in a Medicare Advantage Plan, you can join, switch or drop a plan during the Medicare Advantage Open Enrollment Period, between January 1 - March 31 each year.
  • If you qualify for a Special Enrollment Period.

Special Enrollment Periods

These are times when you can join, switch or drop your Medicare drug coverage if you meet certain requirements. Generally, you must stay enrolled in your Medicare drug plan for the entire year, but you may be able to change your coverage mid-year if you qualify for a Special Enrollment Period. 

How do I switch?

You can switch to a new Medicare drug plan by simply joining another drug plan during one of the times listed above. You don't need to cancel your old Medicare drug plan. Your old Medicare drug plan coverage will end when your new drug coverage begins. 

How do I drop a Medicare drug plan?

You can only drop your Medicare drug plan at certain times. You can dis-enroll by calling 1-800-MEDICARE. You can also send a letter to the plan. If you drop your plan and want to join another Medicare drug plan later, you have to wait for an enrollment period. You also may have to pay a late enrollment penalty if you don't have creditable prescription drug coverage.

Review the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC) your plan sends you each year. The EOC gives you details about what plan covers, how much you pay and more. The ANOC includes any changes in the coverage, costs, provider networks, service area and more that will be effective in January. 

How much do I pay?

Your actual drug plan costs will vary depending on:
  • Your prescription and whether they're on your plan's formulary and depending on what: "tier" the drug is in.
  • Which phase of your drug benefit that you're in
  • The plan you choose. Remember, plan coverage and costs can change each year.
  • Which pharmacy you use.
  • Whether you get Extra Help paying your Part D costs.
You may be able to lower the cost of your prescriptions. Some ways include choosing generics over brand name or paying the non-insurance cost of a drug. You can also send your receipts to your plan to have these costs counted toward your yearly out-of-pocket expenses.



Which drugs are covered?

You can contact the plan for its current formulary, or visit the plan's website. You can also visit the Medical Plan Finder at Medicare.gov/plan-compare, or call 1-800-MEDICARE, TTY users can call 1-877-486-2048.

Each month that you fill a prescription, your drug plan mails you an "Explanation of Benefits" (EOB) notice. Review your notice and check it for mistakes. 

Coverage rules for certain drugs:
  • Prior authorization: You and/or your prescriber must contact the drug plan before you can fill prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
  • Quantity limits: Limits on how much medication you can get at a time.
  • Step therapy: In most cases, you must try one or more similar, lower-cost drugs before the plan will cover the prescribed drug.
  • Prescription safety checks at the pharmacy: Before your prescriptions are filled, your Medicare drug plan and pharmacy do extra safety checks, like checking for drug interactions and incorrect dosages. These checks also include checking for possible unsafe amounts of opioids and the use of opioids at the same time.
  • Drug Management Program: Some Medicare drug plans have a program in place to help you use these opioids and benzodiazepines safely. If you get opioids from multiple doctors or pharmacies, your plan will contact the doctors who prescribed these drugs to make sure they are medically necessary and hat you're using them appropriately.
The opioid safety reviews at the pharmacy and the Drug Management Programs generally don't apply to you if you have cancer, getting palliative or end-of-life care, are in hospices or live in a long-term care facility. 


Medication Therapy Management (MTM) Program
Additional service added to those plans with Medicare prescription drug coverage. This will help them understand how to manage their medications and use them safely. The MTM services offered may vary in some plans. They are free and usually include a discussion with a pharmacist or health care provider to check your medications.

The pharmacist or health care provider  may talk with you about:
  • How well  your medications are working
  • Whether your medications have side effects
  • If there might be interactions between the drugs you're taking
  • Whether your costs can be lowered
  • Other problems you're having
Visit Medicare.gov/plan-compare to get general information about the program eligibility for your Medicare drug plan or for other plans that interest you.






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