All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

Most Medicare drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.

The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.
A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.

When you get a quote from PA Medquote, you will know what your costs are for the year. This information is used in comparison of plans. Overall, you could make these payments throughout the year in a Medicare drug plan:

Your actual drug coverage costs will vary depending on:

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs.
Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $4,130 on covered drugs in 2021, you’re in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.

FOR BRAND NAME PRESCRIPTIONS

Once you reach the coverage gap, you’ll pay no more than 25% of the cost for your plan’s covered brand-name prescription drugs. You’ll pay this discounted rate if you buy your prescriptions at a pharmacy or order them through the mail. Some plans may offer you even lower costs in the coverage gap. The discount will come off the price that your plan has set with the pharmacy for that specific drug.
Although you’ll pay no more than 25% of the price for the brand-name drug, almost the full price of the drug will count as out-of-pocket costs
to help you get out of the coverage gap. What you pay and what the manufacturer pays (95% of the cost of the drug) will count toward your out-out-pocket spending. Here’s a breakdown:

What the drug plan pays toward the drug cost (5% of the cost) and dispensing fee (75% of the fee) aren’t counted toward your out-of-pocket spending.

Example:

Mrs. Anderson reaches the coverage gap in her Medicare drug plan. She goes to her pharmacy to fill a prescription for a covered brand-name drug. The price for the drug is $60, and there’s a $2 dispensing fee that gets added to the cost, making the total price $62. Mrs. Anderson pays 25% of the total cost ($62 x .25 = $15.50).

The amount Mrs. Anderson pays ($15.50) plus the manufacturer discount payment of $42 ($60 x .70 = $42) count as out-of-pocket spending. So, $57.50 counts as out-of-pocket spending and helps Mrs. Anderson get out of the coverage gap. The remaining $4.50, which is 5% of the drug cost ($3) and 75% of the dispensing fee ($1.50) paid by the drug plan, doesn’t count toward Mrs. Anderson’s out-of-pocket spending.

If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan’s coverage has been applied to the drug’s price. The discount for brand-name drugs will apply to the remaining amount that you owe.

FOR GENERIC DRUGS

Medicare will pay 75% of the price for generic drugs during the coverage gap. You’ll pay the remaining 25% of the price. The coverage for generic drugs works differently from the discount for brand-name drugs. For generic drugs, only the amount you pay will count toward getting you out of the coverage gap.

Example:

Mr. Evans reaches the coverage gap in his Medicare drug plan. He goes to his pharmacy to fill a prescription for a covered generic drug. The price for the drug is $20, and there’s a $2 dispensing fee that gets added to the cost. Mr. Evans will pay 25% of the plan’s cost for the drug and dispensing fee ($22 x .25 = $5.50). The $5.50 he pays will be counted as out-of-pocket spending to help him get out of the coverage gap.

If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan’s coverage has been applied to the drug’s price.

ITEMS THAT COUNT TOWARDS THE COVERAGE GAP:

ITEMS THAT DON’T COUNT TOWARDS THE COVERAGE GAP

You may find it necessary to get help paying for prescriptions even after enrolling in Medicare Drug Coverage (Part D). For example, you may reach the annual spending limit and enter what is called the coverage gap. Here are 6 tips to consider if you think you might need to get help with the costs of prescription drug coverage.

1. Consider switching to generics or other lower-cost drugs.

There may be generic or less-expensive brand-name drugs that would work just as well as the ones you’re taking now. Talk to your doctor to find out if these are an option for you. You might also be able to lower prescription costs by using mail-order pharmacies.

2. Choose a Medicare drug plan that offers additional coverage during the gap.

There are plans that offer additional coverage during the Medicare drug coverage gap, like for generic drugs. However, plans with additional gap coverage to help pay for prescriptions may charge a higher monthly premium.Check with the drug plan first to see if your drugs would be covered during the gap

3. Pharmaceutical Assistance Programs. 

Some pharmaceutical companies offer programs to help pay for medications for people enrolled in Medicare drug coverage (Part D). Find out whether there’s a Pharmaceutical Assistance Program that can lower prescription costs for the drugs you take.

4. State Pharmaceutical Assistance Programs.

Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs. Find out if your state has a State Pharmaceutical Assistance Program.

5. Apply for Extra Help.

Medicare and Social Security have a program called Extra Help—a way for people with limited income and resources to get help with prescription costs. If you qualify for Extra Help, you could pay no more than:

6. Explore national and community-based charitable programs like these that help pay for medications:

If you join a Medicare Advantage Plan, you’ll usually get drug coverage through that plan. In certain types of plans that can’t offer drug coverage (like Medical Savings Account plans) or choose not to offer drug coverage (like certain Private Fee-for-Service plans), you can join a separate Medicare drug plan. If you’re in a Health Maintenance Organization, HMO Point-of-Service plan, or Preferred Provider Organization, and you join a separate drug plan, you’ll be disenrolled from your MedicareAdvantage Plan and returned to Original Medicare.

You can only join a separate Medicare drug plan without losing your current health coverage when you’re in a:

Joining a Medicare drug plan will not affect your Medicare Supplement Plan