Tag: Part D

Medicare does not provide coverage for medications. There are two ways to receive prescription coverage, enroll in a Part D plan or receive coverage through a Medicare Advantage Plan.


The average monthly premium for a Part D plan is $55.50 in 2024. High-income Medicare beneficiaries can expect to pay an income-related monthly-adjusted amount, in addition to the premium. Most pay the standard amount. If you do not enroll when you are first eligible, you may be subject to a penalty. The Extra Help financial assistance program is available for qualified individuals.


Most plans will have a yearly deductible and a maximum out-of-pocket cost. After that amount is met, Medicare will pay up to 75 percent of prescription costs. There are plans available that offer first-dollar coverage with no deductible and the coverage starts immediately.


Most plans will have copayments or coinsurance. Medicare ensures that copayments are no more than 25 percent of the full cost of a prescription, and plans are required to pay no less than 75 percent.

Copayments Waived

Live in a long-term care nursing facility and are enrolled in both Medicare and Medicaid.

Plan waives the copayment for certain medications.

The pharmacy opts to waive the copayment for specific medications.

Once your plan reaches a maximum limit, then you enter the coverage gap when Medicare will stop paying. Leaving you responsible for 100 percent of your prescription cost.

Creditable Coverage

As a policyholder, you have the right to know whether or not your current plan meets the standard of creditable by Medicare. All companies offering policies are required by law to notify individuals about the status of benefits, and whether or not their plan meets the standard of Medicare. To be creditable, the policy must pay as much as Medicare.

Creditable Requirements

Provides coverage for brand name and generic.

Reasonable access to retail providers.

Pays an average of 60 percent of prescription cost.

No annual benefit maximum.

The amount payable will be at least $2,000 annually.

Integrated coverage, no more than a $250 deductible per year, no annual maximum, and no less than a $1,000,000 lifetime combined benefit maximum.


Most plans have different requirements. Some require prior authorization from your doctor before certain medications can be filled. Others impose limits on how much you can get at one time. Certain plans require you to try lower-cost drugs before a prescribed medication is covered. Each plan’s formulary is different, make sure the medications you currently take are covered, and your pharmacy is a participating provider.


The best time to enroll is when you are first eligible, during your Initial Enrollment period. If you don’t need coverage now, joining during this period ensures you avoid paying a penalty. Not everyone needs to enroll when they are first eligible, many seniors delay without paying a penalty. Many employer-provided insurance plans offer coverage that is considered creditable coverage by Medicare. If you do have prescription coverage you do not need to join. If you lose coverage (employer benefits end or COBRA ends) you only have a certain amount of time to enroll. The insurance provider will let you know if your coverage is creditable. Keep this documentation safe as you will need to show it to Medicare.


If you go without coverage or another creditable plan for 63 days or more after your initial enrollment ends and then enroll later, you may owe a penalty. Amounts are calculated by multiplying the premium amount by the number of full months you went without creditable coverage. Penalties are added to your monthly premium for as long as you have coverage. If you went 6 months without coverage, your penalty would be .06 (for 6 months without coverage) times (Part D premium). Penalties are recalculated annually.



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Tag: Part D

If you’re considering a Medicare Part D plan, or already enrolled, you may not understand some of the terms used.


The formulary is the list of medications covered by the plan. Categorized into four different tiers with different costs.

Out-of-Pocket Maximum

The out-of-pocket maximum, or limit, is the most you will pay for covered prescriptions in one year. Typically, after you reach this amount in deductibles, copayments, and coinsurance, the plan pays 100 percent of any remaining costs. Once you reach this amount, you will automatically receive catastrophic coverage and will pay a small amount for medications for the remainder of the year. 


Medication is categorized into Tiers. Each Tier will have a different cost.


The least expensive and considered equivalent alternatives to expensive brand-name.

Preferred Brand Name

No equivalent alternative or generic version is available.

Non-Preferred Brand Name

One of the more expensive types of medication.


The highest cost of medication available

Financial Help

For seniors with limited income and resources, financial help is available to help with some of the Part D costs. Qualification for the Extra Help program is based on income and resources.



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Finding Your Level of Extra Help: https://www.medicare.gov/your-medicare-costs/help-paying-costs/extra-help/level-of-extra-help.html

Save on Drug Costs: https://www.medicare.gov/your-medicare-costs/help-paying-costs/save-on-drug-costs/save-on-drug-costs.html

What Drug Plans Cover: https://www.medicare.gov/part-d/coverage/part-d-coverage.html

Generic Drugs: Questions and Answers: https://www.fda.gov/Drugs/ResourcesForYou/Consumers/QuestionsAnswers/ucm100100.htm

Costs in the Coverage Gap: https://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html


Tag: Part D

If you rely on medications, it’s important to review each Part D plan’s formulary, to confirm the prescriptions you need are listed.


Each plan has its list of covered prescription drugs, called a formulary. Medications are classified into tiers, the lowest costing less than those in higher tiers. Be sure to check that your medications are listed. If you don’t see yours listed, search for another plan. These lists often change yearly, meaning your medications may no longer be available next year. Prescription drugs change tiers or move between classifications. Even if you are happy with your coverage, you must review the Annual Notice of Change for the upcoming year to avoid being surprised at the pharmacy. 

Tier 1 – Generic, lowest copayment

Tier 2 – Preferred, brand-name, medium copayment

Tier 3 – Non-preferred brand name, higher copayment

Tier 4 – Specialty, highest copayment


It’s important to know which medications will be covered under the plan, and which are not. Part D does not provide coverage for over-the-counter medications, including cough and cold medicine, and vitamins. Medicare covers some medications that Part D does not. For instance, vaccines, cancer drugs, and certain injectable drugs are covered under Part B if you receive them in an outpatient setting, like your doctor’s office.

Not Covered

In the event your medications are not covered under the plan, there are things you can do.


In many cases, formularies do not cover brand-name drugs but do offer coverage for generic, or low-cost alternatives. Ask your doctor if there is a substitute for the medication that’s not covered under your plan.


Medicare is open to listening to your doctor if he or she believes that a specific drug is the only medication that will help your condition. An exception may be granted if your doctor and Medicare agree that it is medically necessary. You also have the right to file an appeal should Medicare deny your request.

Change Coverage

Each plan is different, and your prescriptions may be covered under a different plan’s formulary. If your current coverage no longer covers your medication, and you find a new plan that does, you can change during Annual Enrollment  (October 15 –  December 7) each year.



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Tag: Part D

The Part D Extra Help Program was created by the Social Security Administration to help seniors with limited income with the costs of Part D plans. Many seniors are unaware of the program and are missing an opportunity to save money on their medication. As a member of Medicare having limited resources, you may be qualified to receive help paying your plan’s premium, annual deductible, and copayments. The program is divided into different levels offering full or partial benefits.


The Social Security Administration determines who qualifies by looking at the value of their total savings, investments, real estate, and income.


Bank accounts, stocks, bonds, mutual funds, retirement accounts, and available cash are all considered to determine financial eligibility. While the value of some real estate in Illinois is considered, your primary residence is not. If you own your home, its value is not considered part of your total resources. In addition to your home, personal items such as jewelry, furniture, and vehicles are not considered. Rental property and life insurance policies are not included as part of your resources either.

Apply Online

You can apply online, by phone, or in person at your local Social Security office. To receive benefits, you will need to provide proof of your Part D plan. After your application is reviewed and qualified, you will receive a Notice of Award from Social Security, documentation that you are qualified and eligible.



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