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What Part D Covers
Did You Know?
The federal government estimates that the 37% of seniors without prescription drug coverage avoid filling their prescriptions, cut pills or skip doses because of cost.**
Medicare Prescription Drug coverage (Part D) was created to help cover the costs of prescription drugs. To enroll in a Part D plan:
- You must be entitled to benefits under Part A and/or enrolled under Part B.
- You must live in the plan's service area.
- You will have to pay an additional premium.
Just like Medigap and Medicare Advantage, Part D is offered by private insurance carriers:
- Most companies offer more than one Part D plan.
- The main differences between plans are:
- The drugs they cover (not all plans cover all Medicare-approved drugs)
- How much the plan costs (your premium)
- How much drugs cost (your copay and coinsurance)
- What limits are placed on drugs (such as quantity limits and prior authorization requirements).
See the Part D plans Medi-CareFirst offers.
There are only two ways to get a Medicare Prescription Drug Plan (sometimes called a PDP):
- A stand-alone Part D Plan
- With most Medicare Advantage (Part C) plans
If you choose to get Part D coverage, it's best to enroll during your initial Medicare enrollment period (three months prior to your 65th birthday to three months after your birthday month).
During this enrollment period, you should think about any future prescription drug needs. You may face late enrollment penalties* if you decide to add drug coverage after the initial enrollment period ends.
The Coverage Gap
Most Medicare Prescription Drug Plans have a coverage gap. It's called a "coverage gap" because you receive coverage at the beginning (before the "initial limit") and coverage at the end (after the "catastrophic limit"), but you may pay for most of the coverage in the middle.
- For the most part, this "gap" is predetermined and set by the government.
- The limits - dollar amounts - on each side of the gap change every year.
- From the time you start your plan until you hit the initial coverage limit, your plan helps cover your drug costs.
- Once your prescription drug costs exceed the initial coverage limit, you fall into the gap. In the gap, you pay 86% of the cost for Generic drugs and the discounted cost for brand drugs.***
- If your out-of-pocket costs exceed the "catastrophic limit," your plan picks up most of the drug cost again.
If you need extra help paying prescription drug costs, programs exists for people who meet minimum income requirements.
* Penalties can apply if you don't join a Medicare Prescription Drug Plan when you are first eligible for Medicare Part A and/or B, and you go without creditable prescription drug coverage for 63 continuous days or more.
** Kaiser Family Foundation (www.kff.org), Prescription Drug Trends, November 2005, p. 2, Fact Sheet (#3057-04).
*** Members (those not already receiving "Extra Help") get discounts on most covered Part D brand-name drugs in the coverage gap. Discounts are based on agreements between the federal government and certain drug manufacturers. For this reason, most, but not all, brand-name drugs are discounted.
Plan Resources
Additional Information
- Enrolling in a Part D plan does not replace your need for Medicare or your current Medigap plan.
- BlueRx (PDP) plans cover all drugs that Medicare has approved for Part D.
- Sign up when you become eligible or you may have to pay a penalty.
We administer Maryland's SPDAP program
Find out what it is and if you're eligible.