Unpacking Medicare: What do I need to know about Medicare Part D coverage?

Medicare Part D helps to cover the cost of your prescription drugs. Here's what you need to know about Medicare Part D as you figure out the best plan for you.

What does Medicare Part D cover?

Medicare Part D helps you pay for most of your prescribed medicines. Original Medicare does not usually cover prescription drugs.

Learn more about the different parts of Medicare

How do I get Medicare Part D coverage?

You can get prescription drug coverage in two ways:

• Enroll in a stand-alone Medicare Part D plan. This coverage can be added to your Original Medicare and Medicare Supplement plans.
• Enroll in a Medicare Advantage (Part C) plan that includes prescription drug coverage. This plan will combine your medical and drug coverage.

Tip: If you don’t sign up for prescription drug coverage when you’re first eligible, you might have to pay a penalty. Find out how to avoid penalties.

Can I change my Medicare Part D plan if my prescription needs change?

Each year, you can change your Medicare plan during the Annual Enrollment Period (October 15 to December 7). Read about enrollment periods.

If you qualify for Extra Help to pay for Medicare costs, there may be more times you can switch your drug plan. Learn more about your options for help with Medicare costs.

How do I know what drugs are covered by Medicare Part D?

Check their formulary (drug list). Every Medicare plan that covers prescription drugs has a list of drugs it covers. This list is called a formulary (or drug list). When you look at a plan, you should check if your drugs are on their drug list.

Check for drug tiers. The drug list will also show you which Medicare drug tier each drug is on. A tier is like a cost level. The lower the tier, the less you pay. For example, you’ll usually pay less for a drug on Tier 1 than on Tier 4. Not all plans have the same tiers. Some plans may have three tiers. Other plans may only have one tier.

Find generic or brand name drugs. Your formulary will include both brand name and generic drugs. Generic drugs are just as safe and effective as brand-name drugs. This is confirmed by the U.S. Food and Drug Administration (FDA). Talk to your doctor to see if a generic drug is right for you.

Search all Part D plans. Medicare has a helpful tool called the Medicare Plan Finder. You can use it to plug in the names of your drugs and find plans in your area that will cover them.

Watch for changes. A plan can make small changes to their drug list during the year. Plans usually don’t remove drugs or move them to a higher tier. If a drug on your list changes, you’ll be told about it.

How do I read a Medicare Part D covered drug list (formulary)?

A Medicare plan’s drug list will show you details you need to know about your drug. There are three key things to look for on a drug list. That's the drug name, the drug tier and any drug rules or limits:

What happens if my prescription drug isn’t covered?

Medicare rules say there must be at least two drugs from each therapeutic class (drug type) in a formulary. But sometimes, you might need a drug that isn’t on the list.

If this happens, your doctor can ask the insurance company to cover it. This is called a "formulary exception." If the drug is approved, it’ll be placed in Tier 4. You’ll pay the cost share for Tier 4 drugs.

How much will my prescription drugs cost with Medicare?

A few things affect how much you’ll pay for your prescriptions.

• The plan you choose. Each plan sets its own cost-sharing by tier. Ask your plan about discounts, like lower prices for 90- or 100-day supplies.
• Whether your pharmacy is in your plan’s network. You usually need to use an in-network pharmacy for your drugs to be covered. Some plans have preferred pharmacies where you could save even more.
• Whether your drug is on the drug list. Plans usually only cover drugs on their drug list. They’ve negotiated lower prices for these drugs, so using them will save you money.
• What tier your drug is on. Plans place their drugs on different tiers, which affect costs. Usually, the lower the tier, the less you pay.
• Whether your plan has a deductible. With a deductible, you pay for the full cost of your drugs until you meet the deductible amount.
• Whether you qualify for help with costs. There are programs to help people with limited incomes pay Medicare drug costs. Learn how you may be able to qualify for help.
  

Your payments may vary throughout the year. It will depend on how much you spend on prescription drugs. That’s because your cost-share will depend upon the benefit phase you’re in.

Drugs filled in a non-retail setting, such as long-term care or specialty mail, might cost more than the price listed on Medicare Plan Finder. You can call the number on your Aetna® ID card to obtain non-retail pricing.

Are there special rules I need to think about before I sign up for a prescription drug plan?

Some drugs have special rules. Your plan will require you to follow these rules before it will cover these drugs. These rules might include:

• Step therapy: If this is the first time you’re prescribed a certain drug, you might need to try a less expensive version first.
• Prior authorization: Your doctor will need to get approval before the plan will pay for the drug.
• Quantity limits: Certain drugs, like opioids, will have limits on the number of doses and refills your plan will cover.

Your plan’s drug list will tell you which drugs need step therapy, prior authorization and quantity limits. If your drug falls into any of these categories, you might need to take action before the plan will cover it. Talk to your doctor about your options.

How can I get the most from my prescription drug benefits?

To get the most out of your Medicare drug benefits, check what extras your plan offers.

• Use in-network pharmacies. Find out which pharmacies are in your plan’s network and stick to those.
• Use preferred pharmacies. Find out if your plan offers preferred pharmacies. You may save even more.
• Order 90- or 100-day supplies. Some plans offer a lower cost for 90- or 100-day supplies of medicine. Even if the price is the same, it means fewer trips to the pharmacy and less chance of missing a refill. A long-term supply is for drugs you take regularly. They’re used to treat long-term conditions like high blood pressure.
• Mail order delivery. Your plan might offer mail order delivery for prescription drugs. Check if there’s a lower cost when you order a long term supply of your drug through the mail. For example, some Aetna Medicare plans offer lower costs on mail order prescriptions through CVS Caremark® Mail Service Pharmacy.

Take time to research your plan options based on your drug needs, costs, and convenience. Finding the right plan at the right price means one less thing to worry about.

Aetna and CVS Caremark® are part of the CVS Health® family of companies.