Prescription Drug Plans (Part D)

Formulary tiers determine how much you pay for different medications. Typically, lower tiers include generic drugs with lower copayments, while higher tiers include brand-name and specialty drugs with higher costs. A common structure includes Tier 1 for preferred generics, Tier 2 for non-preferred generics, Tier 3 for preferred brand-name drugs, Tier 4 for non-preferred brand-name drugs, and Tier 5 for specialty medications. Understanding your medications' tier placement helps predict your costs.

If your medication isn't covered, you have several options. You can request a formulary exception where your doctor explains why you need this specific drug. Your plan may approve coverage based on medical necessity. Alternatively, you can discuss therapeutic alternatives with your doctor or pharmacist – medications in the same class that are covered by your plan. During Annual Enrollment, you can also switch to a plan that covers your medication.

Many Part D plans offer mail-order pharmacy services that can provide convenience and cost savings. Typically, you can receive a 90-day supply of maintenance medications delivered to your home. This often costs less than getting the same medications monthly at retail pharmacies. Mail-order services usually include automatic refill options, pharmacist consultations by phone, and online ordering tools. They work especially well for medications you take regularly.

Generally, no. If you join a Medicare Advantage Plan that includes prescription drug coverage (MA-PD), you already have Part D benefits and cannot enroll in a separate standalone plan. If you're in a Medicare Advantage Plan without drug coverage (rare), you can sometimes add a standalone Part D plan. If you have Original Medicare, you can and should enroll in a standalone Part D plan for prescription coverage.

Part D plans have specific pharmacy networks, which may impact coverage when traveling. Most national plans include major pharmacy chains throughout the U.S., allowing you to fill prescriptions while traveling domestically. Before traveling, check if there are in-network pharmacies at your destination. Consider getting vacation overrides for extended trips or using mail-order options. For international travel, Part D generally doesn't cover medications purchased outside the U.S., so plan accordingly.

The most effective way to compare plans is based on your specific medications. Make a complete list of your prescriptions, including dosages and frequency. Use Medicare's Plan Finder tool or get assistance from our experienced agents to compare how each plan covers your drugs, what pharmacies you can use, and your estimated annual costs. Consider both premium and out-of-pocket costs, as the lowest premium plan isn't always the most affordable overall.

If you enter a skilled nursing facility or hospital, your Part D plan still covers your prescribed medications. However, if you're in a skilled nursing facility receiving Medicare Part A benefits, some medications may be covered under Part A instead of Part D. Once your Part A skilled nursing coverage ends, all prescribed medications would be covered by your Part D plan again, subject to your plan's formulary and cost-sharing requirements.

You can change your Part D plan during the Annual Enrollment Period (October 15-December 7) for coverage starting January 1. If you're enrolled in a Medicare Advantage Plan with drug coverage, you can also make changes during the Medicare Advantage Open Enrollment Period (January 1-March 31). Additionally, certain life events may qualify you for a Special Enrollment Period to make changes outside these times, such as moving outside your plan's service area or losing other drug coverage.