Have questions about Medicare Part D? Explore answers to common questions about prescription drug coverage, costs, enrollment, ways to save and getting help with your plan.
The Medicare prescription drug benefit, Part D, provides coverage for outpatient prescription drugs purchased at retail, mail order, home infusion, and long-term care pharmacies.
Unlike Medicare Parts A and B, which are administered directly by the federal government, Medicare Part D is delivered through private insurance plans. Under the Part D program, Medicare contracts with private insurers that are approved to offer prescription drug coverage. These plans operate under annual contracts with Medicare and are subject to federal oversight and receive federal subsidies. To obtain Part D coverage, beneficiaries must enroll in a standalone prescription drug plan (PDP) or a Medicare Advantage plan with drug coverage (MA-PD plan) offered by one of these participating insurers.
While the specific costs will vary depending on the plan you select, Part D beneficiaries are responsible for covering some costs:
- Monthly premium. This is a payment made to the insurance company that sells the plan that you select. This payment keeps your prescription drug coverage active.
- Annual deductible. The amount of money you must pay yourself for your medications before your insurance company starts covering any of the costs. Certain plans waive the deductible, meaning your insurance company will begin paying immediately.
- Co-payments and/or co-insurance. Co-payments are fixed dollar amount payments you must make for medications when you pick them up at the pharmacy. Co-insurance means you cover a fixed percentage of the cost of the medication.
- Annual out-of-pocket cap. Once your out-of-pocket costs for covered drugs reach the annual cap, you pay nothing more for covered Part D drugs for the rest of the year.
Qualified low-income individuals can receive help with their Part D costs for premiums, deductibles and co-pays through the Part D Low-Income Subsidy (or “Extra Help”). You can apply through the Social Security Administration.
Your costs can change during the year, for example once you meet your deductible or reach the annual out-of-pocket cap. When selecting a plan, it is important to carefully examine the way the plan is structured to understand what costs you will be responsible for. To learn more about the Part D benefit design and selecting a plan that suits your needs, please refer to the 2027 Open Enrollment Guide.
For more information about Medicare Part D, visit http://www.medicare.gov/part-d/index.html.
Visit Medicare.gov to learn more about signing up for prescription drug coverage.
Every state has a State Health Insurance Assistance Program (SHIP) that offers free one-on-one counseling and assistance to people with Medicare and their families. SHIP offices are located throughout each state. To find contact information for the SHIP office closest to your community, visit www.ShipHelp.org or call 1-800-MEDICARE (TTY: 1-877-486-2048).
The Annual Open Enrollment for Medicare prescription drug coverage is October 15 – December 7. This will be the one time that all people with Medicare can join or change their Medicare drug plan for the following year.
Every year, plans make changes to benefits and costs, and some plans are leave the market. With these changes, your current plan may or may not be the best plan for you for the next year. It is important to use this time period to compare your plan choices and find the plan that best meets your prescription drug needs at the lowest cost.
Extra Help (also known as the Low-Income Subsidy) is available for those who meet certain income and resource limits. If you are eligible, Extra Help can mean significant cost savings on your prescription drugs.
To determine if you or someone you know is eligible: visit Medicare.gov or call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778).
The Medicare Prescription Payment Plan (MPPP) is a free, optional program that lets you pay your out-of-pocket drug costs in monthly amounts spread across the year, instead of all at once at the pharmacy. It is available in every Part D plan, and you can sign up by contacting your plan.
You have the right to get a written explanation from your Medicare drug plan if your doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor, or if you are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug.
The Medicare drug plan’s written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan’s decision.
You have the right to ask your Medicare drug plan for an exception if you believe you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary.” Additionally, you have a right to ask for an exception if you believe you should get a drug you need at a lower cost-sharing amount.
If you believe that any of these situations apply to you, you should contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug that is not on your drug plan’s formulary or believe you should get a drug you need at a lower cost-sharing amount.
You should also refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan. When you contact your Medicare drug plan, be ready to tell them:
- The prescription drug(s) that you believe you need.
- The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.
- The date you were told that the prescription drug(s) is not covered.
If you disagree with a coverage or payment decision by your Medicare drug plan, you can file an appeal. For additional information on appeals: https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals