Part D: Prescription Drug Plans
Medicare Part D went into effect on January 1, 2006. Anyone with Part A or Part B is eligible for Part D.
It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD).
All of these plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized.
Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. This is called a formulary. Medicare requires that plans cover a range of drugs in the most commonly prescribed categories and classes. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates.[1][2] Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.[3]
It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid will pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
What does Medicare Part D cost?
Most Medicare Prescription Drug Plans charge a monthly premium that varies by plan. You pay this in addition to the Medicare Part B premium. If you belong to a Medicare Advantage Plan (Part C) or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium you pay to your plan may include an amount for drug coverage.
In addition to the monthly premium there are other costs associated that can vary greatly. These include:
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Yearly deductible
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Copayments or coinsurance
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Costs in the coverage gap
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Penalty for late enrollment
Your actual drug plan costs will vary depending on:
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The drugs you use
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The plan you choose
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Whether you go to a pharmacy in your plan's network
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Whether the drugs you use are on your plan's formulary
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Whether you get Extra Help paying your Medicare Part D costs
Look for specific Medicare drug plan costs, and then call the plans you're interested in to get more details. If you have limited income and resources, your state may help you pay for Part A and/or Part B. You may also qualify for Extra Help to pay for your Medicare prescription drug coverage.
