FAQ for Beneficiaries

What is Medicare Prescription Drug Coverage (Part D)?

The Medicare prescription drug benefit, Part D, helps Medicare beneficiaries pay for outpatient prescription drugs purchased at retail, mail order, home infusion and long-term care pharmacies.

Unlike Parts A and B, which are administered by Medicare itself, Part D is “privatized.” That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy (i.e., enroll in a plan) offered by one of these companies.

What are the costs associated with Medicare Part D?

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 who sells the plan that you select. This payment keeps your prescription drug coverage active.
- Annual deductible. The amount of money you must pay for your medications before your insurance company will start covering any of the costs. Certain plans waive the deductible, meaning your insurance company will begin paying immediately.
- Co-payments and/or co-insurance. Copayments 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.

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”), which is administered by the Social Security Administration.

As you move through the different phases of the Part D benefit, the costs you are responsible for will change. 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 2022 MAPRx Open Enrollment Guide. The 2023 Guide will be released in October 2022.

For more information about Medicare Part D, visit http://www.medicare.gov/part-d/index.html.

How do I sign up for Medicare Prescription Drug Coverage?

Visit Medicare.gov to learn more about signing up for prescription drug coverage.

Open Enrollment for Coverage in 2023

The Annual Open Enrollment for Medicare prescription drug coverage in 2023 (Part D) is October 15, 2022 – December 7, 2022. This will be the one time that all people with Medicare can join or change their Medicare drug plan for 2023.

Plans are making changes to benefits and costs, and there are also new plans in many areas of the country. With these changes, your current plan may or may not be the best plan for you in 2023. It is very 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. All plans will make changes in 2023.

How can I get help to pay the costs of Medicare Prescription Drug Coverage?

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 1-800-772-1213/1-800-325-0778.

What if I am having a problem with my Medicare prescription drug 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.

What if I sign up late for Medicare Prescription Drug Coverage?

The late enrollment penalty is an amount that is added to a person’s Part D premium.

A person enrolled in a Medicare drug plan may owe a late enrollment penalty if one of the following is true:

He or she didn’t join a Medicare drug plan when first eligible for Medicare Part A and/or Part B, and he or she didn’t have other creditable prescription drug coverage that met Medicare’s minimum standards.
He or she had a break in Medicare prescription drug coverage or other creditable coverage of at least 63 days in a row.

The late enrollment penalty (also called the “LEP” or “penalty”) is added to the person’s monthly Part D premium for as long as he or she has Medicare prescription drug coverage. This penalty is required by law and is designed to encourage people to join a Medicare drug plan when they’re first eligible or to keep other creditable prescription drug coverage.

The late enrollment penalty amount changes each year. The person will have to pay it each month as long as he or she has Medicare prescription drug coverage, even if the person changes his or her Medicare drug plan.

FAQ for Beneficiaries

The Medicare prescription drug benefit, Part D, helps Medicare beneficiaries pay for outpatient prescription drugs purchased at retail, mail order, home infusion and long-term care pharmacies.

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 who sells the plan that you select. This payment keeps your prescription drug coverage active.

Annual deductible. The amount of money you must pay for your medications before your insurance company will start covering any of the costs. Certain plans waive the deductible, meaning your insurance company will begin paying immediately.

Co-payments and/or co-insurance. Copayments 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.

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”), which is administered by the Social Security Administration.

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.

The Annual Open Enrollment for Medicare prescription drug coverage in 2023 (Part D) is October 15, 2022 – December 7, 2022. This will be the one time that all people with Medicare can join or change their Medicare drug plan for 2023.

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 1-800-772-1213/1-800-325-0778.

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 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.

The late enrollment penalty is an amount that is added to a person’s Part D premium.

A person enrolled in a Medicare drug plan may owe a late enrollment penalty if one of the following is true:

He or she didn’t join a Medicare drug plan when first eligible for Medicare Part A and/or Part B, and he or she didn’t have other creditable prescription drug coverage that met Medicare’s minimum standards.

He or she had a break in Medicare prescription drug coverage or other creditable coverage of at least 63 days in a row.

The late enrollment penalty amount changes each year. The person will have to pay it each month as long as he or she has Medicare prescription drug coverage, even if the person changes his or her Medicare drug plan.

Calculate your Part D Late Enrollment Penalty here.

Watch a video explaining the Part D Late Enrollment Penalty.