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.
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
|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.
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.
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.