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Medicare’s Open Enrollment Period: What you need to know
From Oct. 15—Dec. 7 each year, people with Medicare can make changes to their coverage for the following year.
Medicare Part D helps cover the cost of prescription drugs. Part D is optional and only provided through private insurance companies approved by the federal government. However, Part D is offered to everyone who qualifies for Medicare. Costs and coverage may vary from plan to plan. Read on to learn more about Medicare Part D prescription drug coverage, how to get it and what it covers.
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Each Medicare Part D plan uses a list of approved drugs to decide what’s covered and what isn’t. This list is called a
Some medications may not be covered by your Medicare Part D plan. This could depend on your plan’s formulary, which may limit coverage of some drugs based on medical necessity, cost or safety.
Some prescription drug plans may have restrictions on certain medications. These can include:
If you have trouble getting the medication that you want covered, you may be able to appeal. You and your doctor can submit a formal request for an exception to a drug coverage rule. For example, you could send a request to get coverage for a drug that’s not in your formulary. You could also send a request to waive a step therapy requirement to use a lower-tier drug.
Your costs for Medicare Part D consist of several different payments. The exact amount of these costs may vary depending on your plan, what tier a drug is in or what pharmacy you use.
For most prescription drug plans, you will pay a premium, or a monthly fee. This premium is paid in addition to the one you pay for Medicare Part B.
If your income is above a certain limit, you may pay a monthly adjustment payment in addition to your prescription drug premium. See this
For many plans, you may have to pay a certain amount each year for your prescription drugs before the Medicare drug plan kicks in to cover costs. This amount is called the yearly deductible. For 2025, no Medicare drug plan may have a deductible higher than $590.
After you meet your deductible, your plan may require you to pay for part of the cost of your prescriptions. This amount is called a copayment or coinsurance.
For most Medicare prescription plans, there is a temporary limit on what the plan covers. This is called the Coverage Gap, also known as the donut hole. In 2024, this Coverage Gap will be triggered once you and your plan spend a combined $5,030 on covered medications. Once you’re in the Coverage Gap, you will pay no more than 25% of the cost for covered Part D drugs in your plan.
In 2024, once your total drug costs reach $8,000 (including certain payments made by other people or entities, including Medicare’s Extra Help program, on your behalf), you’ll move to the catastrophic coverage stage. This means you won’t have to pay a copayment or coinsurance for covered Part D drugs for the rest of the calendar year.
There is some good news on the horizon for Part D drug coverage. In 2025, the
Depending on your income, you may qualify for Extra Help. Extra Help is a program that assists those with limited resources in paying for their Medicare prescription drug costs.
You may automatically qualify for Extra Help if you have Medicare and are enrolled in any of the following programs:
Even if you don’t automatically qualify, you can
Typically, if you qualify for Medicare, you qualify for Part D prescription drug coverage. But it’s important to keep in mind that you may enroll in Part D coverage only in a few specific periods:
The Part D late enrollment penalty is an amount that’s permanently added to your Part D premium if for 63 days in a row you don’t have Medicare drug coverage or other creditable drug coverage. “Creditable drug coverage” refers to a drug plan that pays at least as much as Medicare Part D on average.
To avoid paying the late enrollment penalty, it’s important to enroll in Medicare Part D or have other creditable drug coverage during your IEP. Make sure to enroll in Part D if you lose your creditable drug coverage. If you keep your creditable drug coverage, it’s a good idea to keep records proving that you are enrolled.
If you already have prescription drug coverage through another plan, there will usually be some coordination of benefits between Medicare and your current drug coverage provider. Depending on your current coverage, Medicare will be either your primary or secondary payer for prescription drug coverage.
See Medicare’s
There are many Medicare Part D plans to choose from, so it’s important to find the 1 that works best for you. Be sure to check the plan’s formulary, or list of approved drugs, as well as the pharmacy network. Medicare.gov has
Many Medicare Advantage plans include Part D prescription drug coverage. Check out
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