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Medicare Part D Prescription Drug Coverage Explained

What is Medicare Part D?

Medicare Part D helps pay for the cost of prescription drugs. You can get Part D included in your Medicare Advantage plan or through a standalone Part D plan from a private insurance company.

What does Medicare Part D (prescription drug coverage) cover?

Part D covers brand-name, generic, and specialty medications. Each plan has a list of drugs it covers, known as a formulary.

How much does Medicare Part D cost?

Your costs when enrolled in a Part D plan include:

  • 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

As your prescription medication spending increases throughout the year, you move from one stage to the next. You start at the initial coverage stage at the beginning of each year. All Part D drug plans have the same stages.

Deductible stage
UPMC for Life plans do not have a deductible for prescription drugs. If your plan does have a deductible, you will pay the full price for your drugs until you meet your Part D deductible.
Initial coverage stage
Your plan begins to pay for your covered prescriptions. You pay a copay or coinsurance, depending on the drug tier until your total yearly costs reach $4,430. The total yearly drug costs are the drug costs paid by both you and your Part D plan. Most people will stay in this stage for the entire year.
Coverage gap stage
You pay up to 25% of the plan’s cost for brand-name and generic drugs plus a portion of the dispensing fee. You remain in this stage until your out-of-pocket costs, as well as any manufacturer’s discount payments provided for brand-name drugs, reach $7,050. After that, you move into the catastrophic coverage stage.
Catastrophic coverage stage
Once you reach this stage, you pay the greater of 5% or $3.95 for a generic drug (or a drug treated like a generic). For all other drugs, you pay the greater of 5% or $9.85.

Am I eligible for Medicare Part D?

You must have Original Medicare Parts A and B to join a Part D plan.

How do I get Medicare Part D?

  • You can join a stand alone Part D prescription drug plan. A stand alone Part D plan would be in addition to Original Medicare or a Medicare Supplement plan.
  • Most Medicare Advantage plans include Part D prescription drug coverage. If you have a Medicare Advantage plan, you cannot also join a separate standalone Part D plan.

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 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.

PACE/PACENET
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 Pennsylvania PACE.

Veterans Administration (VA)
To see if you qualify for Veterans Administration benefits, visit va.gov or go to your local VA facility.

Next Steps

This information is not a complete description of benefits. Call 1-866-400-5077 (TTY: 711) for more information. Out-of-network/Noncontracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711).

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal.

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Last Updated: 10/01/2021