Choosing a Medicare Part D prescription drug plan can feel confusing at first. Plans may have different monthly premiums, drug lists, pharmacy networks, and rules for filling prescriptions. The plan that works well for a friend or neighbor may not be the best fit for you.
The most important point is simple: choose a plan based on the medicines you take and the pharmacies you prefer. Medicare Part D plans are offered by private insurance companies approved to provide Medicare drug coverage. Benefits, premiums, drug coverage rules, and pharmacy networks can vary by plan, carrier, and state.
Start With Your Current Medication List
Before comparing Part D plans, make a complete list of your prescriptions. Include the name of each drug, the dosage, how often you take it, and whether you use a brand-name or generic version.
It can also help to write down medications you expect to take regularly in the near future. For example, if your doctor has discussed starting a new medicine, you may want to consider that when comparing plans.
Bring your list to your doctor or pharmacy if you need help confirming the details. Even a small difference in dosage or drug type can affect how a plan covers it.
What Is a Part D Formulary?
A formulary is a plan’s list of covered drugs. Every Medicare Part D plan has its own formulary. Plans generally cover many common prescriptions, but they do not always cover every drug in the same way.
Plans place drugs into tiers, or cost levels. Lower tiers often include preferred generic drugs. Higher tiers may include brand-name or specialty medications and may have higher out-of-pocket costs. A drug may be covered by more than one plan, yet fall into a different tier under each plan.
When reviewing a formulary, look for each medication on your list. Then check its tier and any coverage rules that apply. Do not assume that a plan covers a drug simply because it covers a similar medication.
What Coverage Rules Should You Check?
Some Part D plans may use rules to manage certain prescriptions. These rules are common, but they are important to understand before enrolling.
- Prior authorization: The plan may require your doctor to provide information showing why the drug is medically appropriate.
- Step therapy: The plan may ask you to try a lower-cost drug first before covering another medication.
- Quantity limits: The plan may limit the amount of a drug it covers within a certain time period.
These rules do not always mean you cannot receive a medication. Your doctor may be able to request an exception or provide additional information. Still, a plan with fewer hurdles for your current prescriptions may be easier to use.
Check Your Preferred Pharmacy
Part D plans use pharmacy networks. A pharmacy may be in-network for one plan but not another. Even among in-network pharmacies, your costs may differ.
Many plans have preferred pharmacies. Using a preferred pharmacy can sometimes lower your cost compared with another in-network pharmacy. If you regularly use a local pharmacy, make sure it participates in the plan’s network and check whether it is a preferred location.
Mail-order pharmacy service may also be available through some plans. This can be convenient for medications you take every month, especially if you prefer to receive prescriptions at home. It may not be the best choice for every medication, so compare it with your local pharmacy options.
Look Beyond the Monthly Premium
It is natural to notice the monthly premium first, but the lowest premium may not always mean the lowest overall cost. A plan with a lower premium could place your medications on higher tiers or have higher copayments at your preferred pharmacy.
When comparing plans, consider the full picture:
- The monthly plan premium
- The plan deductible, if one applies
- Your expected copayments or coinsurance for each medication
- Whether your pharmacy is preferred or in-network
- Whether the plan covers your drugs without difficult rules
Your costs may also change during the year based on how much you spend on covered prescriptions. Medicare Part D has coverage stages, and the amount you pay can depend on your medication use. Reviewing estimated yearly drug costs can give you a more useful comparison than looking at the premium alone.
Should You Choose Part D If You Take No Medications?
Even if you do not take prescriptions today, you may want to consider enrolling in a Part D plan when you first become eligible. Health needs can change unexpectedly, and enrolling later without other creditable drug coverage may lead to a late enrollment penalty.
Creditable coverage generally means other drug coverage that is expected to pay, on average, at least as much as standard Medicare drug coverage. Employer or retiree coverage may be creditable, but you should not assume it is. Ask the plan administrator for a written notice about whether your coverage is creditable.
When Can You Choose or Change a Part D Plan?
Most people choose a Part D plan when they first enroll in Medicare. You can also generally review and change your Medicare drug plan during the Medicare Annual Enrollment Period each fall, with new coverage beginning the following year.
Some life events may create a Special Enrollment Period, which can allow changes at other times. Moving outside your plan’s service area, losing other creditable coverage, or qualifying for certain assistance programs may create an opportunity to enroll or change plans.
Because formularies, pharmacy networks, and premiums may change from year to year, it is wise to review your coverage each fall. The plan that fit your needs last year may still be a good choice, but it is worth checking.
Use a Personalized Comparison
A personalized Part D comparison uses your actual medications, dosage amounts, and preferred pharmacies. This approach can help you see which plans may cover your prescriptions and what your estimated costs could look like. Plan details can change, so always review the current plan materials before making a decision.
If you are also considering Medicare Supplement insurance, remember that Medicare Supplement plans generally do not include outpatient prescription drug coverage. You would typically choose a separate Part D plan alongside Original Medicare and a Medicare Supplement plan.
Choosing Medicare coverage is a big step, but you do not have to sort through every detail alone. Eric can help you review your Medicare options, explain how Part D fits with a Medicare Supplement plan, and answer your questions with free, no-pressure guidance.