What is Part D: Prescription Drug Plans?
Prescription Drug Plans (PDPs) are offered by private insurance companies approved by Medicare. Your choices will vary depending on where you live.
You can get drug coverage with a standalone Part D plan or as part of a Medicare Advantage plan (Part C).
In order to enroll into a Part D plan, medicare beneficiaries must be enrolled in Part B.
Two Ways To Get Part D
Option 1: You can get Medicare Part D coverage through a stand-alone Medicare Prescription Drug Plan if you’re enrolled in Original Medicare.
Option 2: If you’re enrolled in a Medicare Advantage plan, you can get this coverage through a plan that includes drug benefits, also known as a Medicare Advantage Prescription Drug Plan (MAPD).
Formularies & Drug Coverage
Every Medicare Prescription Drug Plan has a formulary — that is, a list of covered drugs. The formularies vary among plans.
Late Enrollment Penalty
Medicare Part D coverage is optional, but if you don’t enroll in Part D as soon as you’re eligible, you might pay a late-enrollment penalty if you enroll later. You can use this calculator to estimate your Late Enrollment Penalty.
The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.
Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($33.19 in 2019) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium.
The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.
The coverage gap, commonly referred to ask “The Donut Hole” has several phases. The coverage gap is a temporary limit on what most Part D Prescription Drug Plans or Medicare Advantage Prescription Drug plans pay for prescription drug costs. While you’re in the coverage gap, you might pay higher costs for brand-name and generic drugs. Below we’ve described each phase:
Deductible phase: For most stand-alone Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans, you’ll pay 100% for medication costs until you reach the yearly deductible amount (if your plan has one). The standard deductible for 2019 is $415.
Initial coverage phase: After you’ve reached the deductible, you’ll enter the initial coverage phase, where you will pay the plan’s cost share for covered medications. For example, if your plan benefit includes a 25% coinsurance in this phase and you’re taking a medication that costs $400 a month, your out-of-pocket-cost would be approximately $100 a month.
Coverage gap, also known as the “donut hole”: begins if you and your plan spend a combined $3,820 in 2019 as described above. While in the coverage gap, you’ll typically pay 25% of the plan’s cost for brand-name drugs and 37% of the plan’s cost for generic drugs in 2018. You’re out of the coverage gap once your yearly out-of-pocket drug costs reach $5,100 in 2019.
Catastrophic coverage phase: Begins if your out-of-pocket costs reach $5,100 in 2019. During the catastrophic coverage phase, you’ll only pay a small coinsurance or copayment for covered prescription drugs for the remainder of the year.
Read more about the donut hole and whether or not it will affect you.
It can be a good idea to review your Medicare Prescription Drug Plan coverage every year, to see if your plan covers the medications you need now and may need in the upcoming year.
Frequently Asked Questions
How much is the Part D penalty?
In 2019, Medicare recalculated an individual’s penalty using the 2019 base beneficiary premium ($33.19). So, an individual’s new monthly penalty in 2019 is 1% of $33.19. So if they have missed 36 months, their penalty would be or $11.95 each month. Since the monthly penalty is always rounded to the nearest $0.10, this person pays $12 each month in addition to their plan’s monthly premium.
Here’s the math:
.36 (36% penalty) × $33.19 (2019 base beneficiary premium) = $11.95
$11.95 rounded to the nearest $0.10 = $12.00
$12.00 = An individual’s monthly late enrollment penalty for 2019
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