If you are considering enrolling in the Medicare Part D prescription drug plan (PDP), you need to find out which private drug plans are available in your area and then select the best plan for your needs. Coverage under the Medicare Part D prescription drug program is not handled by Medicare itself. Instead, it is managed by private health insurers and managed health care companies, which offer different plans in different geographic areas.
Before you search online or contact any agency or counselor for help choosing a Part D plan, have the following information handy:
You may enroll only in a plan that operates in your geographic area. The following organizations can give you information about the Part D plans available to you.
Medicare. The Centers for Medicare and Medicaid Services (CMS) has a new Medicare plan finder that can tell you what plans are available where you live and can help narrow your options based on the medicines you regularly take and the pharmacy you use. Medicare gives the PDPs star ratings and let's you compare them against each other based on the exact drugs you take. Go to the Medicare Plan Finder at www.medicare.gov/plan-compare/. Or you can contact CMS by phone at 800-MEDICARE (800-633-4227).
SHIP or HICAP. The State Health Insurance Assistance Program (SHIP), sometimes called the Health Insurance Counseling and Advocacy Program (HICAP), can tell you about the Part D plans available where you live, can identify the plans that cover the drugs you regularly use, and give you information about plan costs. For the nearest SHIP or HICAP office, check the business listings of your white pages phone directory.
State department of insurance. Every state has a government agency that oversees insurance matters. You can contact your state department of insurance for the names, addresses, and phone numbers of all companies that offer a Part D plan in your state.
The best information comes from the plan itself. Before you make a final choice, directly contact any plan that interests you and ask for a complete description of the plan, the drugs it covers, and its costs. They should be able to email you a formulary and summary of benefits describing copays for various tiers of drugs and whether there is a deductible. You can get the phone number and address of any plan from the Medicare website or your state department of insurance.
Deciding which Part D plan is best depends on several factors, including whether you have other health insurance through your employer or union (or your spouse's), whether you qualify for a low-income subsidy, and your age and health. Additional important considerations include:
Your prescriptions. The prescription medications you regularly take, or their generic equivalents, must be included on the plan's formulary (its list of covered drugs). If not, the plan is useless to you. If you cannot find a plan that includes all of your drugs, look for one that covers your most expensive drugs.
Costs. The costs of a Part D plan can vary in several ways. Premium payments often vary, but the copayment amounts are more important. Most plans have tiered copayments, meaning the copayments differ for generic versus brand-name drugs and for different classes of medications. Compare the copayment amount under each Part D plan you're considering for each drug you take.
Coverage gap. Determine what the plan's coverage is like within the so-called "coverage gap" (also known as the "donut hole"). Once your total yearly medication expense reaches a certain amount ($4,130 in 2021), Medicare allows Part D to require you to pay up to 25% of the cost of your drugs, meaning your copays may be higher while you're in the donut hole. But some plans may charge you lower copays even while in the donut hole.
Access restrictions. You must determine whether a plan places any access restrictions on your drugs, such as prior authorization, generic drug or equivalent drug substitution, step therapy, or supply limits. The fewer restrictions a plan has regarding your drugs, the better for you.
Pharmacies. For many people, obtaining their medications from a nearby, helpful local pharmacist is important. If two or more plans offer similar coverage, the type and location of the pharmacy from which you can get your drugs through each plan may help you decide. In addition, check what the plan's prices are for 90-day mail-order prescriptions.
Restrictions on coverage. Insurance companies may impose many different types of restrictions on their Part D coverage. For example:
Part D drug coverage is available through either a stand-alone prescription drug plan (PDP) or as the prescription drug component (called an MA-PD) of a Medicare Advantage managed care plan. Both options offer equivalent coverage, although each plan is different and costs vary.
You enroll in a Part D plan by signing up directly with the plan you want to join. Private insurance companies administer each Part D plan using their own enrollment forms and procedures.
If you do not enroll in a Part D plan when you are first eligible for it, your premiums will be higher when you do finally enroll because Medicare charges an additional 1% for each month you delay enrolling. So, if you intend to enroll in a Part D plan as soon as you are eligible for Medicare, you should do the paperwork ahead of time.
If you qualify for Medicaid, you will be automatically enrolled in a Part D plan. However, you may switch plans if you find one better suited to your needs. (To learn more about Medicaid, read Nolo's article Medicare and Medicaid: What's the Difference?.)
To learn more about Medicare Part D and other health insurance options for your retirement years, read Nolo's article Medicare Part D Prescription Drug Coverage: The Basics or get Social Security, Medicare & Government Pensions, by Joseph L. Matthews and Dorothy Matthews Berman (Nolo).
Updated November 30, 2020