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TPMO DISCLAIMER: “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”


How does Part D work?

Annual Deductible — There is a deductible you must pay for a Part D plan. Your deductible may be different, or waived entirely, but the max amount you can be charged is $480 in 2022. You will pay a discounted price for your medications until you have satisfied the deductible. After that, you begin initial coverage.

Initial Coverage — During initial coverage, you pay a copay for your medications based on your plan’s formulary. Each prescription drug plan separates its medications into tiers. Each tier has a copy amount for which you are responsible. It is typically separated by generic drugs, preferred name brands, even more specialized medications, and etc. In 2022, the initial coverage cap is $4,430. After you and the insurance company together have paid this amount, then you enter the coverage gap.

The Coverage Gap – During the coverage gap, you will still generally have significant discounts for generic medications. Typically, you will pay 25% for name brand medications and 37% for generics. Your gap spending will continue until you have paid $7,050 out of your own pocket in 2022.

Catastrophic Coverage – If you should spend past the coverage gap, your plan will begin to pay 95% of the costs of your formulary medications for the rest of the year.

What is Medicare Part D?

Medicare Part D is a federal prescription drug plan administered through private insurance companies. Medicare beneficiaries can enroll in a standalone Part D drug plan that either supplements their Original Medicare or they can choose a Medicare Advantage plan that also features prescription drug coverage.

A Part D plan is insurance for necessary prescription medication. You pay a monthly premium to an insurance company for your Part D plan. There is a copay or percentage cost to you, but the insurance company will pay for part of your prescription medication. You will receive a separate Part D insurance card that is separate from your other Medicare-related cards.

Medicare Part D

What's Covered

Each Medicare Part D plan has a formulary — a list of medications it covers. Medicare requires the plan must offer at least two drugs in each class. Also, each plan cover all — or nearly all — prescription drugs in these classes:

Antidepressants
Antipsychotics
Anticonvulsants Immunosuppressants
Anti-cancer medications
HIV/AIDS drugs

Part D plans also cover common vaccines to prevent illness.

What's Not

Prescription drug plans do not cover any medications Original Medicare covers for you. Other than that, there are a few medications that Part D will not typically cover including:

Weight loss or weight gain drugs
Fertility medication
Over-the-counter medication Erectile dysfunction medication Cosmetic drugs

You may find a Part D carrier that offers these medications, but it is not the norm. The above list is not a complete one. If you do feel you need a drug that is not on a formulary you would like to be on, you have the right to ask for an exception.