Which parts of Medicare do you need? What do they cover? How much do they cost? How do you get coverage? Many people have these same questions, and in this blog series, we are breaking apart Medicare to make it easier for you to navigate the journey.

We’ll cover Part A and B — also known as Original Medicare — as well as Medicare Advantage coverage (Part C), Medigap plans, and prescription drug coverage (Part D). We’ll also address how and when you should sign up for Medicare and how you can help a loved one with their Medicare options.


If you’ve been following our Medicare blog series, “The Medicare Journey,” you’ve learned the ABCs of Medicare. In this post, we’ll cover Part D — prescription drug coverage. Medicare Part D is prescription drug coverage provided by private insurance companies like Highmark.

PrescriptionsMany prescriptions can be costly or even completely unaffordable for most people if purchased out-of-pocket — including specialty drugs for cancer and other conditions, which can cost thousands of dollars each month.

To help people avoid crippling prescription costs, Medicare drug coverage plans are available to everyone with Medicare. You will have to join a Part D plan that is run by an insurance company or by another private company that is approved by Medicare. All Medicare Part D plans vary by premium, drug copays, and in which drugs they cover on their approved drug list.

When Can You Get Medicare Drug Coverage?

To enroll in a Medicare prescription drug plan, you must be eligible for Original Medicare. For most people, the election time for Medicare Part D is during Medicare’s Annual Enrollment Period (Oct. 15 – Dec. 7).

You should also be aware of several time periods for joining and managing your enrollment in a Medicare Part D plan:

This Medicare video may help you better understand the Medicare Part D enrollment periods.

 

How Can You Get Medicare Drug Coverage?

There are two ways you can get drug coverage through Medicare plans:

If you purchase a Medicare Advantage plan, it may include prescription coverage. If it does not, you can add a Medicare Part D plan to your coverage. Part D plans also add drug coverage to Original Medicare (Part A & B).

It’s important to note that if you join a Medicare drug plan, it may effect your current “regular” Medicare plan coverage. If you have a Medicare Advantage plan that includes prescription drug coverage and you decide to join a Medicare Part D plan, you will be removed from your Medicare Advantage plan and enrolled in Original Medicare instead.

It’s important to know how Medicare Part D works with other insurance so you don’t inadvertently un-enroll from coverage you want.

What Do Medicare Drug Plans Cover?

Like health plans, coverage varies across Medicare Prescription Drug plans. Each plan has a list of covered drugs — known as a formulary — and many Medicare drug plans will “tier” their formularies. Drugs in each tier have different costs, and each tier may include brand name and generic drugs as well as “as needed” and maintenance drugs.

You will want to check your medications against plans’ formularies to be sure you select a plan that meets your needs. You can find out if your drugs are covered under Highmark plans with our online drug search tool.

What Does Medicare Prescription Coverage Cost?

All Medicare plans that offer prescription coverage — Part C as well as Part D plans — vary in cost.

No matter which insurance company or plan you choose, however, you may face out-of-pocket costs like these throughout the year in a Medicare drug plan.

The dollar costs you’ll have in your actual drug plan will vary depending on several factors.

  • The drugs you use
  • The plan you choose
  • Whether you go to a pharmacy in your plan’s network
  • Whether the drugs you use are on your plan’s formulary
  • Whether you get Extra Help paying your Medicare Part D costs

While all drug plans must provide at least a standard level of coverage, Part D plans can vary widely by types of drugs covered, cost sharing (how much you have to pay out of pocket), and the pharmacies you can use. It’s important for you to look beyond plan premiums and compare all prescription drug plan features carefully.

Low Income Subsidies (also called “Extra Help”) are available to help qualified individuals pay for premiums and cost sharing amounts associated with Medicare Part D coverage.

Costs in the Coverage Gap (The “Donut Hole”)

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches a certain threshold.

After you enter the coverage gap, you pay a percentage of the plan’s cost for covered brand name and covered generic drugs until your costs reach a certain amount that is considered the end of the coverage gap. Not everyone will enter the coverage gap.

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