Medicare Questions & Answers: Medicare Part D

Medicare Part D Q&A

Showing 28 questions

Answered by Kevin Truebenbach Medicare Insurance Agent

Kevin Truebenbach

Transition Health Benefits • Brookfield, WI

Why is the new $2,000 out-of-pocket maximum for drug costs important?

The $2,000 out-of-pocket maximum is a significant improvement for those who rely on expensive medications. After reaching this threshold, all additional drug costs will be fully covered by your Medicare Part D plan for the remainder of the year. This means that, for the first time, Medicare enrollees can predict and limit their annual prescription drug spending, offering peace of mind and financial predictability.
Answered by Aisha Saleem Medicare Insurance Agent

Aisha Saleem

Licensed Agent • Baltimore, MD

How do discount cards and resources affect my Medicare Prescription Drug plan?

If you choose to use a discount card to pay for a prescription because it's cheaper than the Medicare Prescription Drug plan, you can use it for the cheaper price. However, it will not count towards your out-of-pocket expenses.
Answered by Ruben Trejo Medicare Insurance Agent

Ruben Trejo

Life & Health Hub, LLC • Conroe, TX

How will the new 2025 Medicare Part D out-of-pocket cap impact seniors and prescription drug costs?

The new 2025 Medicare Part D out-of-pocket cap is a HUGE WIN for seniors! It limits how much they have to spend on prescriptions, making medications more AFFORDABLE, PREDICTABLE, and way less stressful.
Answered by Samantha Jellison Medicare Insurance Agent

Samantha Jellison

Securely Insured LLC • Green Mountain, NC

Why do some seniors end up paying lifelong penalties for Medicare Part B or Part D?

Lack of appropriate retirement planning education. One of the foundations I have built my business on is education. Medicare 101 seminars can be really useful to people to learn how to avoid these penalties.

It is important to know that unless you have what is known as Creditable Coverage, delaying Part B and or Part D can carry lifelong penalties. Each situation is unique so it’s important to consult with a professional to understand if you have Creditable Coverage or not and have a plan in place, months before you turn 65. Sorting out your Medicare coverage is best done up to 3 months before you turn 65.
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

I’ve been on a Part D plan for a while, and I’m wondering why my generic prescriptions suddenly cost more. Did something change?

Your generic prescription costs might be rising because Part D plans update their formularies, premiums, and copays each year, and I’ve seen many people overlook the need to review these changes annually. In my view, it’s a frequent mistake—failing to reassess coverage as costs and policies can shift significantly, especially this past year with the Biden-Harris Inflation Reduction Act taking effect. The Act introduced a $2,000 out-of-pocket cap for 2025, but it also altered how plans and manufacturers share costs, which can increase generic prices depending on your specific plan’s structure.
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

What imbalance exists in prescription drug spending, and how has it impacted overall costs?

A recent report highlighted a stark imbalance where generic drugs, despite being 91.5% of prescriptions, only represent 12.9% of the drug spending, while brand-name drugs, at 8.5%, account for 87.1% of costs. This disparity contributed to an 11.4% increase in drug spending, reaching $450 billion, primarily due to rising costs for treatments of diabetes and obesity.
Answered by Cathy Reeck Medicare Insurance Agent

Cathy Reeck

Licensed Broker • Lawrenceville, GA

For Medicare Part D, why would someone pick a plan with a high total cost?

Beneficiaries need to verify that their drugs are on the formulary. Is their a drug deductible? What are the copays for their specific drugs? IF you medication is not on the $0 premium RX plan,that becomes a VERY expensive mistake. One that will cost them more than a high premium.
Answered by Clarence "Mark" Christiansen Medicare Insurance Agent

Clarence "Mark" Christiansen

Christiansen Insurance Services • Mequon, WI

I have multiple medications; how can I ensure my Medicare Part D plan covers them all without breaking the bank?

medicare.gov has a public website allowing you to input your Rx list including name of drug, milligrams and dosage. Then key in your pharmacy preference to see which Medicare Part D plan will give you the best bang for your buck.
Answered by Melonie Wood Medicare Insurance Agent

Melonie Wood

American Senior Benefits • Westville, FL

Why might Original Medicare with a Part D plan be better than a Medicare Advantage plan for frequent travelers?

It really isn't since original Medicare only pays 80%, the member is responsible for 20% of everything which can become costly. and you have to PAY for Part D every month & pay for your medication. A Medicare Advantage Plan includes drug coverage with Tiers 1 & 2 usually $0 costs , depending g on the plan
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

Why am I paying more for Medicare Part B and D than my friends? What is IRMAA and how is it calculated?

When clients ask why their Medicare Part B and D premiums exceed others’, I attribute it to IRMAA, the Income-Related Monthly Adjustment Amount, which increases costs based on higher income reported on their tax return from two years prior. Medicare discourages advisors like me from quoting specific thresholds, instead directing individuals to consult the official income brackets and resources to determine their financial responsibility two years hence. The calculation uses modified adjusted gross income, and significant income events—such as a large asset sale—can elevate the surcharge, often unexpectedly impacting their total premium obligation.
Answered by Tom Rogala Medicare Insurance Agent

Tom Rogala

Agent/Broker - 35 years • Northville, MI

How do I compare Part D plans to minimize costs for a mix of generic and specialty drugs?

Complete my survey including drug list and dosge. I can shop all drug plans by total cost

(premium, deductible and copays)
Answered by Clarence "Mark" Christiansen Medicare Insurance Agent

Clarence "Mark" Christiansen

Christiansen Insurance Services • Mequon, WI

I'm worried about the 'donut hole' in my Part D plan. How do I manage my medication costs once I enter it?

Don't worry! The dreaded "donut hole" has been discontinued effective January 1, 2025. So you can not longer enter the donut hole. However, Medicare pays less to the insurance companies this year for your prescriptions so most Part D plans now have higher deductibles which will be offset by a $ 2,000 annual limit on the full price of a member's covered Rx costs, so members with expensive name brand drugs will be protected by the new rules. Be careful on this and make sure that all of your prescriptions are in fact covered by your Part D plan.
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

I just started on Medicare Part D, and I’m confused about whether my new cholesterol medication counts toward my coverage gap. Can you explain?

Figuring out how your new cholesterol medication fits into Medicare Part D’s coverage gap can be confusing—it does count toward that limit, depending on your plan’s formulary and annual drug spending. In 2025, once your total costs hit the gap, you’ll reach catastrophic coverage after $2,000 out-of-pocket, lowering your costs to zero for covered meds, and Medicare now sends a statement detailing these expenses to keep you informed. Check that statement or your plan’s formulary for a clear snapshot of your progress!
Answered by William Lawler Medicare Insurance Agent

William Lawler

Living Benefits • St. Louis, MO

My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?

I am diabetic and I am on a Medicare Advantage plan. Insulin costs are capped at $35/mo. Other meds, like Ozempic, are not inexpensive, but they are available.
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

Can Medicare Part D deny coverage for a brand-name drug if a generic isn’t available?

Medicare Part D can’t deny coverage for a brand-name drug just because a generic isn’t available—plans must cover it if it’s on their formulary and medically necessary, based on your doctor’s prescription, though they might require prior authorization or step therapy to justify it over other options. Upon enrollment, I always encourage my clients to call me if their medication regimen changes during the year so we can verify coverage details with the carrier and avoid surprises. I’ve dealt with this plenty, and as long as the drug’s listed and no generic exists, your plan has to honor it under CMS rules, but check your formulary or call your provider to confirm it’s not excluded or restricted. If it’s off-formulary, you’d need an exception, which can be a hassle but doable with your doctor’s help.
Answered by Brian Moore Medicare Insurance Agent

Brian Moore

Ohio Medicare Plan • Dayton, OH

How will the Inflation Reduction Act’s Medicare drug pricing changes really affect seniors?

The Inflation Reduction Act (IRA) brings real relief to seniors by capping your annual Part D out-of-pocket drug costs at $2,000 starting in 2025, eliminating the coverage gap and making prescription expenses much more predictable. What’s less obvious is how temporary premium stabilization credits are keeping Part D premiums low in 2025—once these fade, premiums could climb higher than they might have without the law, possibly offsetting some of your savings down the line. While drug companies now pay penalties for steep price hikes, which helps lower certain copays, I genuinely recommend watching your plan’s premium changes since these credit details weren’t fully emphasized when the law took effect.
Answered by Clarence "Mark" Christiansen Medicare Insurance Agent

Clarence "Mark" Christiansen

Christiansen Insurance Services • Mequon, WI

I'm on a fixed income and struggling to afford my medications. What's this Extra Help program I've heard about for Medicare Part D?

In 2025, single tax filers making up to $ 1,976 monthly gross income with no more than $ 17,600 in assets (couples: $ 2,665 / $ 35,130) should qualify for Extra Help for Medicare Part D also referred to as LIS (Low Income Subsidy). To apply for help, go to ssa.gov/extra help, call Social Security at 800.772.1213, or call your local SS office. Walk in traffic is not recommended.
Answered by Christopher Palazzini Medicare Insurance Agent

Christopher Palazzini

Bankers Life • Jacksonville, FL

I’ve had the same Part D plan for years, but this year my insulin shot up in price. Did the Inflation Reduction Act not fix this yet?

You should be shopping out a Part D plan every single year. No matter what. Whether your meds changed or not. Part D plans change their formularies every year. Inflation reduction act will not help you if the RX is not on the formulary list. Co pays and annual deductibles can apply as well.
Answered by Shane and Tammy Carpenter Medicare Insurance Agent

Shane and Tammy Carpenter

Your Choice Insurance Advisors • Claremore, OK

How does the Part D “catastrophic coverage” phase work once I hit the out-of-pocket max?

If you have met the "catastrophic coverage" phase, you will have no further responsibility towards drugs covered in your plan's formulary. However, if you are on medications not covered by your Part D prescription drug plan, you will still be responsible to pay those costs.
Answered by Larry Dalton Medicare Insurance Agent

Larry Dalton

D&D Ins. Group, LLC • Durant, OK

I'm confused about the different tiers in Medicare Part D plans. How do they affect what I pay for my medications?

Medicare Part D drug tiers are the drug manufacturers' way of controlling costs. It is extremely important to make sure that your drugs are in the formulary, and these tier structures change annually. All Medicare Part D stand-alone drug plans and the Part D drug plans embedded in the Medicare Advantage plans must be analyzed yearly to ensure that you have the proper plan to cover your prescription drugs. Many drug plans utilize the tier structure to determine whether to allow the drug to be used towards the annual deductibles of that drug plan; this should be paid special attention to when selecting a drug plan.
Answered by Lowell Ryals Medicare Insurance Agent

Lowell Ryals

ryals Insurance • Springfield, MO

My pharmacist mentioned the Medicare "donut hole" is going away in 2025. What does that actually mean for me?

It

Means that your prices won’t go up through the year

You may have a deductible with your prescriptions

You can also apply for a leveling out program to keep your copays level through the year
Answered by Michael Yost Medicare Insurance Agent

Michael Yost

BOST Benefits • Youngstown, OH

I want to get a shingles vaccine. Will Medicare cover this preventive service?

Medicare does not cover the shingles shot. The shingles shot is covered under Part D (a prescription plan). Once you enroll in a prescription drug plan, the shingles shot should be covered at 100%.
Answered by Lt Col Tim Brown Medicare Insurance Agent

Lt Col Tim Brown

Insurance Services of KY & TN • Gallatin, TN

What is the main benefit of Medicare Part D?

Co-pays (although not always) are better than the discount cards. The problem is that the government tells you if you don’t get Part D,when eligible, then you’ll be penalized should you want one later and the penalty is forever. That is just wrong. So that is the two reasons to have one. The drug card that is part of Part C Medicare AKA Medicare Advantage plans has no premium associated with that program.
Answered by Renee Brown Medicare Insurance Agent

Renee Brown

HealthMarkets Insurance • Trinity, FL

Is it better to get Medicare Part D or Medicare Advantage?

There really isn't a perfect answer to this question. It is based on what each person's needs and the how they want to be covered. The best choice really is an individual choice and how they look at their insurance needs and money they want to have to spend monthly on their insurance.

More often Part D plans will have a higher Deductible and copay costs over a Medicare Advantage, so looking at each person's medications is a must when deciding on these plans.
Answered by David Didier Medicare Insurance Agent

David Didier

Senior Benefit Advisors • Baton Rouge, LA

What’s the biggest mistake seniors make when choosing a Medicare Part D plan?

Hello ,

On the Part D, (Prescription drug coverage).

I get a list of your prescriptions you are currently taking, then I go to the Medicare.gov

I check what plans cover the drugs and the pharmacies at the lowest cost, so you can get the best prices and control the budget for your cost for the year!

It is best to check all your cost at the pharmacy you use, (it might be costing you a lot, or it might be the best, the Medicare.gov site lets you know, call me, I can help!

Thx!