Medicare Questions & Answers: Medicare Part D
Medicare Part D Q&A
Showing 44 questions
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.
How do discount cards and resources affect my Medicare Prescription Drug plan?
Normally Discount Cards (Good RX and others) may discount your Prescription cost at certain pharmacies. This may be a way to save on Prescriptions when there is a higher copay. These companies may gather your information and market Medicare plans.There are State Resources available to help with Prescription costs. There are many generic medications that could be $0 copay in Medicare Advantage or Standalone RX plan. Brand Medications can have copays.
State programs have an application and can take up to 2 weeks to 4 months to be approved. These programs have income guidelines to qualify. Most do not consider assets.
NJ PAAD
PA PACE
If you have questions on the state resources, please contact me for more information.
How will the new 2025 Medicare Part D out-of-pocket cap impact seniors and prescription drug costs?
A major change coming in 2025 is the introduction of a $2,000 maximum out-of-pocket (MOOP) limit for Medicare Part D plans. This change is part of the Inflation Reduction Act, which aims to lower drug costs for Medicare beneficiaries.
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.
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.
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.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.
For Medicare Part D, why would someone pick a plan with a high total cost?
I don't ever recommend selecting a Part D plan based on premium alone. The only rational way to identify the optimal Part D plan for a client is to base it on the meds they are talking regularly. Once I have the medication list, I enter it into my planning tool so I can see total cost, meaning premium + out of pocket costs. Sometimes, depending on the meds, the premium can be as low as 1.80/mo or it can be 115/mo. You must look at total spend and not premium alone!
I'm a low-income senior who can't afford my prescription drugs even with Medicare Part D. What specific assistance programs should I apply for?
I loved the short answer to this question Apply for LIS/Extra Help! Its easy to do, it doesn't take long and if you are not eligible "NO BIG DEAL"! You don't need to go to any government office and set a future appointment. Just APPLY! You won't regret it!
My pharmacist mentioned the Medicare "donut hole" is going away in 2025. What does that actually mean for me?
Donut hole going away means that your cost will be less that last if your drugs cost was higher enough for you to get into the donut hole.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.
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.
I'm on an expensive specialty medication. Will the 2025 Part D changes help someone in my situation?
In 2025 the most anyone can spend on medications in a Callander year, no matter how many medications they take is $2,000.
I keep hearing about Medicare Part D changes for 2025. Will these actually lower what I pay for my prescriptions?
The biggest change in 2025 was closing the coverage gap also known as the "Donut Hole".If your drugs are covered under your plan's formulary then you will spend no more than $2000 per year, no matter how expensive your prescriptions are. That is great news for folks who have been spending 4,5, 6 even 7 thousand a year. However, if you are taking a very expensive drug that is not covered under the Medicare formulary you could end up spending more than the 2K cap.
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
I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?
Since we now have a $2,000 cap on medications for Part D Medicare per year, this person should only be responsible for $2,000 of out of pocket costs. Insurance carrier will pick up the rest of the cost for the year for Part D drugs.So I heard something about Medicare drug costs being capped at $2,000 in 2025. Is that really happening or just talk?
It is not just talk, it’s really happening. However the drug or drugs must covered in the Medicare formulary. If the drug is not covered then you can expect to pay full cost.
I switched to a new Part D plan and now half my meds require prior authorization. Why didn't anyone warn me this could happen?
Part D plans tend to change every year. You absolutely must review your Part D plan every Annual Election Period (AEP) which is always October 15 - December 7. After that, no changes can be made until the next AEP. Your Medicare Specialist can help you with reviewing your plan for the coming year. All Part D plans are in effect from January 1 - December 31.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.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.
I'm worried about affording my medications even with the 2025 changes. Are there additional assistance programs I should know about?
Even with the coverage gap being eliminated and a max of $2000 out-of-pocket being set, medications can still be costly.Medicare Beneficiaries can:
1) Apply for the Low-income Subsidy (extra help) through Social Security
2) Apply for the state-based program called the Medicare Savings Program
3) Apply for patient assistance programs offered by the drug manufacturers or non-profit organizations.
I'm taking a brand-name medication that doesn't have a generic version. How can I find a Medicare Part D plan that will cover it at a reasonable cost?
Work with an independant agent that has access to all the plans..The changes in 2025 to Part D has caused every plan to review and adjust coverage. Not every plan covers every drug in their forumulary. This was the area I spent the most time on this year for my clients to help them get the coverage needed...
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.I've been dreading hitting the donut hole each year. How will its elimination in 2025 change what I pay throughout the year?
With all the 2025 Medicare Plans & Prescription Drug Plans, once a person reaches $2000 in cost including 25% of the drugs cost towards the $2000, there is no more costs to the member, therefore, no more "donut hole"
My friend says the new Medicare drug payment plan in 2025 will help with her expensive medications. Would it help me too?
In 2025, all Medicare Part D plans have a $2,000 annual out-of-pocket maximum for covered drugs. Medicare has set up a payment plan to help offset the burden of paying for this $2000 cap. Once you reach this limit, your plan will pay 100% for your covered medications for the rest of the year. However, you must still pay your portion of the out-of-pocket costs upfront at the pharmacy or through the payment plan. This cost depends upon the drug's tier and the drug plan’s deductible, which is based upon the different drug plans available.This cost can be easily disbursed through the Medicare payment plan, lowering your monthly drug cost. It does not change that you must pay for upfront or throughout the coming months with the Medicare payment plan.
Your monthly drug cost with this Medicare payment plan is based on what you would have paid out of pocket at the pharmacy for your prescriptions that month, plus your previous month’s balance. It is divided by the number of months left in the year.
In other words, if your out-of-pocket drug cost is $1200 a year, then you would be paying $100 per month. This does not include your premium for the drug plan.
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.So I heard something about Medicare drug costs being capped at $2,000 in 2025. Is that really happening or just talk?
It's very real. Medicare members are capped when your Part D or C plan's actual retail cost of covered drugs reaches $ 2,000 during 2025. Be sure to confirm that all of your meds are listed as "covered" drugs. Check your plan's formulary for that.My pharmacist mentioned the Medicare "donut hole" is going away in 2025. What does that actually mean for me?
The "donut hole" (or coverage gap) in Medicare Part D prescription drug coverage is being eliminated in 2025, meaning once your out-of-pocket costs reach $2,000, you won't pay anything for covered medications for the rest of the year.
I want to get a shingles vaccine. Will Medicare cover this preventive service?
It does under Part D. There is generally no cost. Talk to your doctor and get a prescription. They will take it from there.I'm confused about which vaccines Medicare covers. Can you explain which ones are free?
Medicare Part B covers vaccines for the Flu, COVID, Pneumonia, and Hepatitis B. Part B also covers vaccines if you’re exposed to a harmful virus or bacteria by accident, such as a tetanus shot or rabies shotPart D (prescription drug) plans cover vaccines for RSV, Shingles, Tdap (tetanus, diphtheria, and pertussis/whooping cough), and vaccines that are "reasonable and necessary" to prevent illness and are not covered by Part B. Part D may also cover vaccines required to travel internationally.
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.
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.
How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?
Once you hit the 2,000 max out of pocket everything is Covered 100%There is no Catastrophic phase anymore No donut hole
How do I compare Part D plans to minimize costs for a mix of generic and specialty drugs?
You can always reach out to a professional broker for help in comparing Part D plans. Or, you can go directly to Medicare.gov and click on Health and Drug Plans in the upper right hand corner of the homepage. Then click on compare health and drug plans and enter your zip code. It will allow you to enter all of your prescriptions drugs and compare all available plans in your zip code. The comparison will also show what your monthly costs will be for each prescription. Don't hesitate to call for additional help!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!What's the biggest mistake seniors make when choosing a Medicare Part D plan?
With the changes made in 2025 to the drug formulas and tears, it is wise to analyze all the plans. Cheaper premiums could cost you more in the long run at the pharmacy. I would always investigate the drug plans each year.I'm getting conflicting information about whether Medicare covers my specific medication. How can I get a definitive answer?
This is why it is so important to actually meet with an agent in person who has several carriers they write for. The agent can put the members in the carrier's formulary to make sure the medication is covered
I've been diagnosed with bipolar disorder at age 66. How should I structure my Medicare coverage to ensure I get the mental health care I need?
Yes. The most obvious means toward doing that is to ask your agent what is covered in your policy in the area of mental health and those medications that are prescribed to treat that malady. If you want to compare your current plan with other companies, it is going to be essential for you to realize that mental health is covered by Medicare but only so much. This depends upon the State you live in, unfortunately. You need to call both Supplement firms as well as those who offer Advantage plans. Based on a "side-by-side" comparison, you should have enough ammunition to make a determination. It would have been better had you come to this conclusion before a full 12-months had elapsed after turning age 65. This means that now you will be subject to underwriting though you won't be declined just for a bipolar disorder but an accumulation of health issues that you might also have.I have Original Medicare, a Medigap Plan G, and a Part D plan, but I'm still facing high costs for my specialty medication. What options exist for someone in my situation?
Make sure that your Part D plan has the best possible coverage for your specialty medication. All plans are different and some will cover your specialty meds better than others.I'm in the donut hole and can't afford my medications. What are my options right now before the 2025 changes?
This year of 2025 there are no known holes in the prescription drug plans. All drug plans are mandatory with this feeling of $2000 out-of-pocket expenses for the beneficiary. However, it is important to make sure that your drug plan includes your prescription drugs in their formulary so that you get full benefit of the out-of-pocket expenses.All part D prescription drug plans should be reviewed annually
I need both a psychiatrist for medication and a therapist for talk therapy. How does Medicare coordinate coverage for these different providers?
Medicare provides coverage for both psychiatric medication management and talk therapy through its Part B (Medical Insurance) and Part D (Prescription Drug Coverage) plans.Psychiatric Medication Management
Medicare Part B covers outpatient mental health services, including visits with psychiatrists or other qualified healthcare providers for psychiatric evaluations and medication management. After meeting the Part B deductible, you typically pay 20% of the Medicare-approved amount for these services if your provider accepts assignment. Provider Acceptance: Not all mental health providers accept Medicare. It's important to confirm with your psychiatrist and therapist that they accept Medicare assignment to ensure coverage. Medicare Advantage Plans: If you're enrolled in a Medicare Advantage Plan (Part C), your plan may offer additional mental health benefits beyond Original Medicare. However, provider networks can be more limited, so verify that your preferred providers are in-network