Medicare Part D FAQ

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Medicare Part D FAQ 2017-08-24T12:13:14+00:00
The Medicare Part D program authorizes Medicare-approved private insurance companies to provide prescription drug coverage. You must have Part A or Part B to join a Medicare Prescription Drug Plan. You can get this coverage in the form of a Medicare Advantage Prescription Drug plan (MAPD) if you have both Part A and Part B, or a stand-alone Medicare Part D Prescription Drug Plan, which only requires Part A or Part B. You can generally enroll in any of the Medicare plans that include prescription drug coverage if it serves the area where you live.

The Annual Election Period (or Fall Open Enrollment) for Medicare Part D Prescription Drug Plans lasts from October 15 to December 7 every year. During this time period, anyone with Medicare can enroll in a Medicare Part D Prescription Drug Plan or change from one plan to another.

You can enroll in a Medicare Prescription Drug Plan or change plans anytime if you qualify for Extra Help with your prescription drug costs. Extra Help (also known as the Low-Income Subsidy) is a program that helps beneficiaries with limited income with Medicare Part D costs. Depending on your level of Extra Help, this may include monthly plan premiums, copayments, and deductibles (see below for more information on eligibility requirements).

You may also be able to enroll in, switch, or drop Medicare Prescription Drug Plans during one of the Special Election Periods, which may occur any time of the year that you have a qualifying situation. Some situations that may qualify you for a Special Election Period include (but aren’t limited to) when you move out of a plan’s service area or if you live in a nursing home or other assisted-care institution. Eligibility for the Extra Help program is another situation that qualifies you for a Special Election Period.

  • Costs: Medicare Part D costs can vary by plan and may include premiums, copayments, coinsurance, and deductible expenses. eHealth’s Medicare Part D Comparison Tool can also help you compare annual costs, based on the prescription drugs you take.
  • Preferred pharmacies: Some stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans have preferred pharmacies you can use to pay lower cost sharing. If a pharmacy you use isn’t in the plan’s preferred network, you may have higher copayments and coinsurance costs.
  • Travel: Do you spend a lot of time traveling or staying in other states? If you’re enrolled in a Medicare Advantage Prescription Drug plan or a stand-alone Medicare Part D Prescription Drug Plan, you may want to find out whether your plan provides coverage in another state. In some cases, you may have to pay higher cost-sharing amounts if you fill prescriptions out of the plan’s network.
  • Premium: You pay a monthly premium for a Medicare Part D Prescription Drug Plan, which varies among plans.
  • Deductible: No Medicare Prescription Drug Plan can have a deductible higher than $400 in 2017. However, your actual deductible will depend on the particular plan you choose. Many plans do have a deductible, and you usually pay all of your drug costs up to that amount. Some plans do not have a deductible (called $0 deductible plans), but these plans might have higher premiums and/or higher copayment and coinsurance amounts.
  • Initial coverage stage: Once you reach the deductible amount, you pay a copayment or coinsurance in the initial coverage stage until your total prescription drug costs (including what you pay, plus what your plan pays) reach the coverage gap, which is $3,700 in 2017. The Medicare Part D coverage gap is also called the “donut hole.” Not all plans have a coverage gap or donut hole.
  • Coverage gap: If a plan includes a coverage gap, it begins if and when you leave the initial coverage stage and ends when you spend a total of $4,950 out of pocket in 2017. If you reach the gap in 2017, you generally pay 40% of your plan’s cost for covered name-brand prescription drugs and 51% of your plan’s cost for covered generic drugs. Under the Affordable Care Act provisions, there will be additional discounts in the coverage gap each year through 2020, when the coverage gap will be closed entirely, and you will have continuous Medicare Part D prescription drug coverage.
  • Catastrophic coverage: If and when you reach the out-of-pocket limit in the coverage gap ($4,950) in 2017, you qualify for catastrophic coverage. You pay only a small copayment or coinsurance for covered drugs for the remainder of the year in this stage.

If you are in a Medicare Part D Prescription Drug Plan and qualify for assistance, you can get Extra Help from Medicare to pay your monthly premiums, yearly deductibles, and prescription copayments. The amount of help you receive will depend on your income and resources.

To qualify for the Extra Help program, you must:

  • Live in one of the 50 states or the District of Columbia.
  • Meet the annual income and resource limits, which can change from year to year.

Depending on your income and asset levels, you may be eligible for either full or partial Extra Help. You can contact Social Security (contact information is below) for the most up-to-date eligibility information and to see if you qualify. You automatically qualify for Extra Help if you have any one of the following:

  • You have complete Medicaid coverage.
  • You get assistance from a state Medicaid program for paying Medicare Part B premiums as part of a Medicare Savings Program.
  • You get Supplemental Security Income (SSI) benefits.

If you automatically qualify for Extra Help because of one of the above situations, you may not have to submit an application to apply. Medicare will mail you a purple-colored notice to let you know that you automatically qualify for the program. Once you find out that you qualify, you should enroll in a stand-alone Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, if you do not already have Medicare Part D coverage. Remember, if you have Extra Help, you can enroll in Medicare Part D at any time with a Special Election Period. If you don’t enroll in a Medicare Prescription Drug Plan, Medicare will automatically enroll you in a plan.

Even if you don’t automatically qualify for Extra Help, you may still apply. If you think you may qualify for Extra Help, you can:

  • Call Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. TTY users can call 1-800-325-0778.
  • Visit the Social Security website (
  • Go to your local Social Security office to apply in person.
  • Apply at your state Medical Assistance (Medicaid) office.

There are certain prescription drugs or categories of drugs that the Medicare program does not typically cover. These are called excluded drugs; some Medicare Part D Prescription Drug Plans may include them as an added benefit.

The Centers for Medicare & Medicaid Services (CMS) does not require these categories of drugs to be covered:

  • Weight loss or weight gain
  • Fertility
  • Cosmetic (e.g., hair growth)
  • Cough and cold
  • Non-prescription drugs
  • Over-the-counter smoking cessation (prescription smoking cessation drugs are covered)
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations