Medicare Part D (Prescription Drug Plan) Benefits Overview for 2020
Last Updated : 12/12/20197 min read
Summary: The Medicare Part D program authorizes Medicare-approved private insurance companies to provide prescription drug coverage. You must have Part A or Part B to join a Medicare Prescription Drug Plan. You can get this coverage in the form of a Medicare Advantage Prescription Drug plan (MAPD) if you have both Part A and Part B, or a stand-alone Medicare Part D Prescription Drug Plan, which only requires Part A or Part B.
Medicare Part D: when can you enroll?
There are certain times when you can enroll in a Medicare prescription drug plan.
- When you’re new to Medicare, you get a seven-month Medicare Initial Enrollment Period (IEP). It starts three months before the month you qualify for Medicare, includes your birthday month. Then it continues for three months after that month.
- Your Medicare IEP is a good time to sign up for a Medicare prescription drug plan. If you don’t sign up for this type of plan when you’re first eligible, you might find yourself paying a late enrollment penalty if you decide to sign up later on.
- The Annual Election Period (or Fall Open Enrollment) for Medicare Part D Prescription Drug Plans lasts from October 15 to December 7 every year. During this time period, anyone with Medicare can enroll in a Medicare Part D Prescription Drug Plan or change from one plan to another.
- Suppose you’re enrolled in a Medicare Advantage plan, and it doesn’t cover prescription drugs – or it no longer covers your prescriptions. You can change to a Medicare Advantage prescription drug plan during the Medicare Advantage Open Enrollment Period. Or, you can drop your Medicare Advantage plan altogether, and sign up for a stand-alone Medicare Part D prescription drug plan during this period. It runs from January 1- March 31 every year.
- In some cases, you can enroll in Medicare Part D during a Special Enrollment Period (SEP). For example, if you lose your existing coverage, you might qualify for a SEP.
- You can enroll in a Medicare Prescription Drug Plan or change plans anytime if you qualify for Extra Help with your prescription drug costs. Extra Help (also known as the Low-Income Subsidy) is a program that helps beneficiaries with limited income with Medicare Part D costs. Depending on your level of Extra Help, this may include monthly plan premiums, copayments, and deductibles (see below for more information on eligibility requirements).
You may also be able to enroll in, switch, or drop Medicare Prescription Drug Plans during one of the Special Election Periods, which may occur any time of the year that you have a qualifying situation. Some situations that may qualify you for a Special Election Period include (but aren’t limited to) when you move out of a plan’s service area or if you live in a nursing home or other assisted-care institution. Eligibility for the Extra Help program is another situation that qualifies you for a Special Election Period.
What should I consider when choosing a plan?
- Costs: Medicare Part D costs can vary by plan and may include premiums, copayments, coinsurance, and deductible expenses. eHealth’s Medicare Part D Comparison Tool can also help you compare annual costs, based on the prescription drugs you take.
- Preferred pharmacies: Some stand-alone Medicare Prescription Drug plans and Medicare Advantage Prescription Drug plans have preferred pharmacies you can use to pay lower cost sharing. If a pharmacy you use isn’t in the plan’s preferred network, you may have higher copayments and coinsurance costs.
- Travel: Do you spend a lot of time traveling or staying in other states? If you’re enrolled in a Medicare Advantage Prescription Drug plan or a stand-alone Medicare Part D Prescription Drug Plan, you may want to find out whether your plan provides coverage in another state. In some cases, you may have to pay higher cost-sharing amounts if you fill prescriptions out of the plan’s network.
What are my Medicare Part D coverage costs in 2020?
- Premium: You pay a monthly premium for a Medicare Part D Prescription Drug Plan, which varies among plans.
- Deductible: No Medicare Prescription Drug Plan can have a deductible higher than $435 in 2020. However, your actual deductible will depend on the particular plan you choose. Many plans do have a deductible, and you usually pay all of your drug costs up to that amount. Some plans do not have a deductible (called $0 deductible plans), but these plans might have higher premiums and/or higher copayment and coinsurance amounts.
- Initial coverage stage: Once you reach the deductible amount, you pay a copayment or coinsurance in the initial coverage stage until your total prescription drug costs (including what you pay, plus what your plan pays) reach the coverage gap (or “out-of-pocket threshold”), which is $4,020 in 2020. The Medicare Part D coverage gap is also called the “donut hole.” Not all plans have a coverage gap or donut hole.
- Out-of-pocket threshold (coverage gap): If you and your plan spend $4,020 on covered prescription drugs in 2020, you’ll reach an out-of-pocket threshold. If you reach the threshold in 2020, you generally pay 25% of your plan’s cost for covered name-brand prescription drugs and for covered generic drugs.
- Catastrophic coverage: If and when you reach the out-of-pocket limit in the coverage gap ($6,350) in 2020, you qualify for catastrophic coverage. You pay a copayment or coinsurance for covered drugs for the remainder of the year in this stage.
Does Medicare provide extra help for my Medicare Part D Prescription Drug Plan costs?
If you are in a Medicare Part D Prescription Drug Plan and qualify for assistance, you can get Extra Help from Medicare to pay your monthly premiums, yearly deductibles, and prescription copayments. The amount of help you receive will depend on your income and resources.
To qualify for the Extra Help program, you must:
- Live in one of the 50 states or the District of Columbia.
- Meet the annual income and resource limits, which can change from year to year.
Depending on your income and asset levels, you may be eligible for either full or partial Extra Help. You can contact Social Security (contact information is below) for the most up-to-date eligibility information and to see if you qualify. You automatically qualify for Extra Help if you have any one of the following:
- You have complete Medicaid coverage.
- You get assistance from a state Medicaid program for paying Medicare Part B premiums as part of a Medicare Savings Program.
- You get Supplemental Security Income (SSI) benefits.
If you automatically qualify for Extra Help because of one of the above situations, you may not have to submit an application to apply. Medicare will mail you a purple-colored notice to let you know that you automatically qualify for the program. Once you find out that you qualify, you should enroll in a stand-alone Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, if you do not already have Medicare Part D coverage. Remember, if you have Extra Help, you can enroll in Medicare Part D at any time with a Special Election Period. If you don’t enroll in a Medicare Prescription Drug Plan, Medicare will automatically enroll you in a plan.
Even if you don’t automatically qualify for Extra Help, you may still apply. If you think you may qualify for Extra Help, you can:
- Call Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. TTY users can call 1-800-325-0778.
- Visit the Social Security website (www.socialsecurity.gov).
- Go to your local Social Security office to apply in person.
- Apply at your state Medical Assistance (Medicaid) office.
What prescription drugs are not covered?
There are certain prescription drugs or categories of drugs that the Medicare program does not typically cover. These are called excluded drugs; some Medicare Part D Prescription Drug Plans may include them as an added benefit.
By law, these categories of drugs are not covered by Medicare drug plans:
- Weight loss or weight gain
- Cosmetic (e.g., hair growth)
- Cough and cold
- Erectile dysfunction
- Non-prescription drugs (also called over-the-counter drugs)
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Considering adding a Medicare Part D Prescription Drug Plan to your coverage, or switching the plan you have now? You can compare plans anytime it’s convenient for you. Enter your zip code in the box on this page and see what plans are available where you live.