Prescription Drug Plans

What a Part D plan is

Part D is prescription drug coverage, sold by private insurance companies approved by Medicare. Original Medicare on its own does not cover most prescriptions you fill at a pharmacy, so a standalone Part D plan is how that gap gets filled.

You would add a standalone Part D plan if you have Original Medicare, with or without a Medigap plan. If you are in a Medicare Advantage plan, drug coverage is usually already built in, and enrolling in a separate Part D plan can disenroll you from your Medicare Advantage plan, so it is worth checking first.

Why these plans are not interchangeable

Every Part D plan publishes a formulary, which is its list of covered drugs. Formularies differ from plan to plan, and so do the tiers each drug sits in, the pharmacies the plan prefers, and the rules it applies.

• Tiers. Drugs are grouped into tiers, and what you pay depends on which tier yours falls into.
• Pharmacy network. Many plans charge less at preferred pharmacies, so where you fill matters.
• Coverage rules. Some drugs require prior authorization, step therapy, or have quantity limits.
• Formulary changes. Plans can change their drug lists from year to year.

Two people in the same town taking different medications can be better served by completely different plans. That is why the comparison has to start with your actual prescription list rather than with the premium.

How the coverage stages work

Deductible stage

If your plan has a deductible, you pay the full negotiated price for your drugs until you meet it. Some plans have no deductible, and some apply it only to certain tiers.

Initial coverage stage

You pay a copay or coinsurance for each prescription, and the plan pays the rest.

Catastrophic stage

Once your out-of-pocket drug spending for the year reaches the annual threshold set by Medicare, you pay nothing more for covered drugs for the rest of that year.

The dollar amounts for the deductible limit and the catastrophic threshold are set by Medicare and change each year. We can look up the current figures for the year you are enrolling.

The late enrollment penalty

Help paying for your prescriptions

If your income and resources are limited, federal and state programs can lower what you pay for drug coverage, including Extra Help through Social Security, Medicare Savings Programs run by your state, and assistance offered by some states and drug manufacturers for specific medications.

When we talk I check whether you may be able to get help, and if a program fits, I assist with the application. Eligibility is determined by the government agencies that run each program, not by me. You can also apply directly through Social Security or get free one-on-one counseling from your State Health Insurance Assistance Program.

When you can enroll or change plans

Initial Enrollment Period

The seven-month window around your 65th birthday, starting three months before the month you turn 65.

Annual Enrollment Period

October 15 to December 7 each year, with changes effective January 1. This is when most people review and switch drug plans.

Special Enrollment Periods

Certain changes, such as moving or losing other creditable drug coverage, open a window outside the usual dates.

Because plans can change their formularies, premiums, and pharmacy networks every year, a plan that served you well this year may handle your medications differently next year. A yearly review is the point of the Annual Enrollment Period.

How I help

I start with your list: every medication, the dose, and the pharmacy you prefer. Then I check how the plans available in your county handle each one, including tier placement and any coverage rules, and show you what your total yearly cost would look like under each. You choose, and I handle the enrollment.

My help costs you nothing. Agents are paid by the insurance companies, and your premium is the same with or without me.