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Medicare Part D Prescription Drug Coverage Explained

What is Medicare Part D?

Medicare Part D, also called prescription drug 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).

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

Part D helps cover brand-name, generic, and specialty medications. Prescription coverage varies by plan; each plan has a list of drugs that are covered by that plan, 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

Your Part D coverage changes throughout the year as your spending increases. Each covered drug belongs to a tier which determines how much you will pay.

Deductible Stage
UPMC for Life does 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
You pay: A copay or coinsurance, depending on the drug tier.
Costs that apply in this stage: When your total cost (the amount both you and the plan pay added together) reach $4,020, you move to the Coverage Gap Stage.

Coverage Gap Stage
You pay: 25 percent of the total cost for your medications (plus a portion of the dispensing fees for brand-name drugs).
Costs that apply in this stage: Your out-of-pocket costs for generic drugs. Your out-of-pocket costs plus 70 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 $6,350, you leave the Coverage Gap Stage. This applies to all prescription drug plans.

Catastrophic Coverage Stage
You pay: 5% percent of the cost for each of your drugs or $3.60 for generics and $8.95 for brand-name (whichever is greater) for the remainder of the year.

Prescription drug coverage example
Stages 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 2 generic drug copay of $9.
Plan pays: the remaining $21.

A total of $30 ($9 your cost plus $21 plan’s cost) is accumulated. You have $3,990 ($4,020 - $30) left in the Initial Coverage Stage.
Coverage Gap Stage You pay: A maximum of 25% of the total cost of $30. Your cost would be $7.50.

A total of $7.50 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 $3.60 for a generic drug.

You total would be $3.60, as it is greater than 5% of the total $30 drug cost.

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 standalone Part D prescription drug plan. You can have a standalone Part D plan in addition to Original Medicare or a Medicare Supplement plan.
  • Most Medicare Advantage plans offer Part D prescription drug coverage included. 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: 10/01/2020
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