Part D coverage is offered through Medicare-approved private insurance companies. You can receive Part D coverage through a prescription drug plan (PDP) or by including it in a Medicare Advantage prescription drug plan (MAPD).
Part D helps cover brand-name and generic medications. Prescription coverage varies by plan; each plan has a formulary that lists the drugs that are covered by that plan.
Your costs when enrolled in a Part D plan:
- Your Part D plan monthly premium, if applicable
- Any out-of-pocket costs such as copays, coinsurance, and deductibles included with the prescription drug plan that you choose
- A late enrollment penalty (this only applies if you have a period of 63 days without Part D coverage)
Stages of prescription drug coverage
Initial Coverage Stage
You pay: The deductibles, copays, and coinsurance for your prescription drug plan, as applicable.
Costs that apply in this stage: Your out-of-pocket costs plus the costs paid by your prescription drug plan. Once these costs reach $3,750, you move to the Coverage Gap Stage.
Costs that apply to the Catastrophic Coverage Stage: Only your out-of-pocket costs.
Coverage Gap Stage
You pay: A maximum of 44 percent of the cost for generic drugs and 35 percent of the total cost of brand-name drugs (plus a portion of the dispensing fees).
Costs that apply in this stage: Your out-of-pocket costs for generic drugs. Your out-of-pocket costs plus 50 percent of the total cost for brand-name drugs.
Costs that apply to the Catastrophic Coverage Stage: The costs that apply in this stage plus your total out-of-pocket costs from the Initial Coverage Stage. Once these costs reach $5,000, you leave the Coverage Gap Stage. This applies to all prescription drug plans.
Catastrophic Coverage Stage
You pay: A reduced copay or coinsurance on all covered drugs until the end of the year.
Prescription drug coverage example
|Initial Coverage Stage
||In this example, the total cost of a Tier 2 generic drug is $30.
You pay: Your plan’s deductible first (if applicable). Then you pay your plan’s Tier 1 generic drug copay of $10.
Plan pays: the remaining $20 for the same generic drug.
A total of $30 ($10 your cost plus $20 plan’s cost) is accumulated. You have $3,720 ($3,750 - $30) left in the initial coverage stage.
|Coverage Gap Stage
||You pay: A maximum of 44% of the total cost of $30. Your cost would be $13.20.
A total of $13.20 is accumulated in the coverage gap stage. Only your costs are accrued in this stage.
|Catastrophic Coverage Stage
You pay: The greater of 5% or $3.35 for a generic drug or a drug treated like a generic drug and 5% or $8.35 for all other drugs.
Extra help with prescription drug costs
Centers for Medicare & Medicaid Services
The government offers extra help for Part D prescription drug costs. To see if you qualify, call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. Or you can visit online at www.medicare.gov.
Medical Assistance (Medicaid)
To see if you qualify for medical assistance from the state (Pennsylvania), call 1-800-692-7462 Monday through Friday from 8:30 a.m. to 4:45 p.m. TTY users should call 1-800-451-5886.
To see if you qualify for medical assistance from the state of Ohio, call 1-800-324-8680 Monday through Friday from 7 a.m. to 8 p.m. and Saturday from 8 a.m. to 5 p.m.
Pennsylvania offers help to older adults for prescription drug coverage. Call 1-800-225-7223 from 8:30 a.m. to 8 p.m., Monday through Friday, and 9 a.m. to 3 p.m. on Saturday. TTY users should call 1-800-222-9004. Or you can visit online at https://pacecares.magellanhealth.com/.
Veterans Administration (VA)
To see if you qualify for Veterans Administration benefits, visit online at www.va.gov or go to your local VA facility.