Part D Prescription Plans

How to get drug coverage?

  • Stand-alone Medicare Prescription Drug Plan (Part D)
  • As part of a Medicare Advantage Plan (Part C)

Cost associated with a Medicare Part D Drug plan?

  • Monthly Plan Premium
  • Plans Yearly Deductible – $0-$415
  • Initial Coverage Level Copays – Tier level copays
  • Coverage Gap (Donut Hole) – 25% of brands; 37% of generics in 2019
  • Catastrophic Coverage – in 2019, 5% or $3.40 for generics, $8.50 for brand drugs (whichever is greater)

Late Enrollment Penalty

The late enrollment penalty is an amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without creditable prescription drug coverage. The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage. 

Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($33.19 in 2019) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.

Part D Definitions to know

  • Formulary – a list of drugs that the plan covers.
    • Each plan includes at least 2 drugs in the most commonly prescribed categories and classes.
  • Prior authorization – to make sure certain prescription drugs are used correctly and only when medically necessary. This means before your plan will cover a certain drug, you must show the plan you meet certain criteria for you to have that particular drug.
  • Formulary Exceptions – drug plan’s decision to cover a drug that’s not on its drug list.
  • Tiering Exceptions – drug plan’s decision to charge a lower amount for a drug that’s on its non-preferred drug tier.
  • Step Therapy – type of prior authorization; you must first try a certain, less expensive drug on the plan’s formulary that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug.
  • Quantity Limits – plans may limit the amount of prescription drugs they cover over a certain period of time, for safety and cost reasons.


    For more information click here or call (866) 994-2338.

Data from Medicare.gov