Part D Plans: Medicare Prescription Coverage

Prescription Drug Plan details

by Ray Wilson+ on Aug 21, 2013 | 3 Comments

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Part D plans are prescription coverage for seniors with Medicare or Medicare Advantage. We’ve broken down how prescription drug coverage works for you now that you’re over 65.

Two Ways to Get Drug Coverage

1) Medicare Prescription Drug Plan (Part D). You get these drug plans through Original Medicare. If you have a Medigap plan you’ll need to enroll in a separate drug plan, as new Medigap plans do not include prescription coverage.  You may need to enroll in a drug plan with some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.

2) Medicare Advantage Plan (Part C) or other Medicare health plan that offers Medicare prescription drug coverage. You replace Original Medicare’s Part A and B with this plan, and many times prescription drug coverage is offered. You may need to enroll separately if your plan does not offer Rx coverage.

What Prescription Plans Cover

Each Rx plan has its own drug formulary (drugs the plans cover). Most plans place drugs in tiers, with each tier having a different cost. There are exceptions to your cost such as if your prescriber (doctor) feels that a higher tiered drug will work better for you than a lower tiered drug, you may receive the higher tiered drug at a lower copay.

Part D Costs

Generally your premium is $31.16 per month, however if you get a Medicare Advantage plan your premium is bundled in.

Medicare Part D Donut-Hole

This is a gap in coverage after you reach $2,970 (a combined spending total from you and Medicare) you reach the donut-hole. During this time you will pay 47.5% of brand name drugs, and 79% of generic drugs in 2013 (25% by 2020). However, what you pay for brand name drugs in your coverage gap, as well as the drug companies’ discounts,  will count towards your out-of-pocket costs to help you get out of the donut-hole.

For example if you buy a drug that is $60 plus a dispensing fee of $2, you would pay $29.45 for the drug BUT $59.45 will count towards your out-of-pocket costs for your brand name drugs. During the coverage gap, this does not apply to generic drugs. Only what you pay toward generic drugs count toward your out-of-pocket costs.

For further questions or help enrolling please call 800-930-7956 or contact Senior65.

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Reader Comments and Questions

By ed on February 14, 2019

I have a drug plan with express scripts. Upon renewal they now say they won't cover certain drugs which were covered before. Can I change drug companies mid stream?

You are always able to switch Part D drug plans during AEP open enrollment (Oct 15-Dec7). You typically cannot switch at other times. If your current drug is no longer covered, you can work with your licensed agent to appeal. If you worked with a Senior65 agent to enroll in your Drug Plan, give us a call.
-Chris @

By Jerome on January 25, 2019

For Part D coverage: I'm 83, wife is 78. No drug coverage to date. We both have many prescribed drugs. Are on a fixed income (SS under $2000 per month, small pension, under $1000 per month. Grateful for advice -- thank you!

Hello Jerome,
If you have not yet enrolled in Part D drugs we can help you. If you are new to Medicare you can get coverage starting the first of the month. If you have had Medicare for over 6 months you will have to wait until the Annual Election Period (AEP), which occurs from October 15th to December 7th of every year. I know it's long ahead but if you give us a call during this time we can help you enroll.

When you call in, please have the name and doses of the drugs you currently take. This will allow us to make a smart recommendation.

-Chris from

By saphrey on August 23, 2018

my sister is 80 years old. she had a prescription insurance plan through an insurance co. She canceled it years ago because she took no prescription drugs. She wants to enroll in a plan, but she needs answers. If she enrolls will she have to pay a penalty? Or is there an enrollment time she can enroll and not have to. The ins agent she had it with before told her she had to pay a large penalty no matter when she enrolled. She needs a plan that won't be expensive. she lives on social security and is a widow. can you help me get some answers to help her. She has a friend with silver scripts. But if there is a special plan to help seniors, please tell me about it.

Typically, the time to enroll in a Medicare Part D drug plan is between Oct 15 through Dec. 7 during Medicare Open Enrollment. There are penalties for going without Part D coverage and they grow the longer you are without coverage. We always recommend keeping your coverage active. Your sister's case is unique so it is hard to say how Medicare will assess any penalties without knowing more. Please give us a call and we can help calculate her potential penalty as well as identify the right plan to cover her RX moving forward.
-Michelle from

PLEASE NOTE: We cannot comment on specific Medicare claims. Contact Medicare directly if you are trying to see if your issue is covered.

We will not publish your last name or email if you submit this form.

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