Prescription Drug Plans

Prescription Drug Plans (Medicare Part D)


  • Beneficiaries must be eligible for Part A and/or enrolled in Part B
  • Beneficiaries must live in the plan’s service area
  • Plans must enroll all eligible beneficiaries regardless of health status. (Except: in limited circumstances with MAPD and SNP plans)

When beneficiaries opt for Original Medicare, they often select a Medigap policy to help cover medical costs and a stand-alone PDP plan to defray prescription drug costs. Choosing a PDP is voluntary, however, if a plan is not selected when first eligible for Medicare insurance, a lifetime penalty is levied by Medicare

When a Medicare Advantage Plan with Drugs is selected, the prescription plan is embedded in one policy that covers Medicare Part A, Part B and Part D. The characteristics of either choice are identical. The component parts are:

  • A deductible. (A plan may or may not have a deductible up to the Medicare defined maximum.)
  • Initial Phase. Costs are shared between beneficiary and company
  • Gap Phase (Donut hole). Cost shares change
  • Catastrophic Phase. Copays for drugs are very inexpensive
    Note: Annually, Medicare dictates the deductible maximum, when each phase begins, and the copay amounts and/or percentages
  • When selecting a PDP plan, one should consider premiums, cost sharing, formulary, network pharmacies and other factors
  • Extra help for low income beneficiaries is available
  • Beneficiaries with income higher than $85,000 (individual) or $170,000 (couple) pay a higher Part D premium
  • Plan coverage is provided through network pharmacies. (Varies by plan.)
  • Plans must meet the Medicare standard coverage
  • Some plans include enhanced coverage for an additional monthly premium

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