Medicare Part D FAQs

There’s a lot to understand when it comes to Medicare Part D. To make a well-informed, confident decision about your Medicare Part D options, you should know all you can. What questions do you have? Whatever they may be, we hope to answer them here.

Browse our list of the most frequently asked questions about Medicare Part D and find your answer below.

Q. What’s the difference between PDP and MA-PD plans?

A. An MA-PD plan is a Medicare Advantage Prescription Drug Plan. It combines prescription drug coverage with the benefits and services of Medicare Part A and Medicare Part B. A Prescription Drug Plan (PDP) is stand-alone prescription drug coverage. Learn more about PDP vs. MA-PD.

Q. What does Medicare Part D cover?

A. This answer varies depending on which specific plan you choose. Each plan has a formulary (list of drugs) with various prescription drugs covered by that plan. Learn more about formularies.

Q. How do Part D plans work?

A. There are four stages in Medicare Part D plans: the Deductible stage, the Initial Coverage stage, the Coverage Gap (Donut Hole) stage, and the Catastrophic Coverage stage. You can learn more about how coverage works here.

Q. What is a formulary?

A. A formulary is a list of drugs a Part D plan covers. Many Medicare prescription drug plans separate drugs into different tiers within the formularies. Drugs in different tiers have different costs. For example, a drug in a lower tier will typically cost less than a drug in a higher tier. Learn more about Medicare Part D formularies.

Q. What is the “Donut Hole”?

A. The Donut Hole, also called the Coverage Gap, is a stage in Medicare Part D reached after you and your plan spend a certain amount of money. When you reach the Donut Hole, you will be responsible for a higher portion of your prescription drug costs. This lasts until you reach your true out-of-pocket drug spending, and then you will enter the Catastrophic Coverage stage.

Q. What is the Affordable Care Act’s effect on the Donut Hole?

A. The Affordable Care Act is helping to close the Donut Hole by requiring health plans to offer additional coverage and brand name prescription drug companies to offer a discount on those drugs when plan members are in the Coverage Gap. By the year 2020, the Coverage Gap will be eliminated entirely.

Q. What is different about an out-of-network pharmacy?

A. An out-of-network pharmacy does not have a contract with a provider’s specific plan to coordinate or provide covered drugs to members of the plan. Most prescription drugs you fill at these pharmacies are not covered by the plan and are therefore more expensive. Learn more about Medicare Part D pharmacies.

Q. What’s the difference between Medicare Part D plans?

A. Companies that offer Medicare Part D will offer plans with different levels of coverage, like basic and enhanced plans. Enhanced plans may cost you more each month, but offer greater coverage on more expensive prescription drugs. Some enhanced plans even offer partial coverage in the Donut Hole.

Q. What if I can’t afford Medicare Part D coverage?

A. If you can’t afford Part D coverage, you may qualify for Extra Help from Medicare. This program is available through the federal government and provides qualified Medicare beneficiaries with help needed to pay for their prescription drugs. Learn more about the Extra Help program now.

Q. How do I choose a Part D plan?

A. There are many factors to consider when deciding which Part D plan is right for you, including the number of prescription drugs you take, what pharmacy you use, what type of prescription drugs you take (brand vs. generic), how healthy you are and do you have other health insurance coverage. Visit our Steps to Choosing a Part D Plan page to learn more.

Q. How do I enroll in a Part D plan?

A. You have a few options. During a proper enrollment period, you can enroll on the plan’s website, on www.medicare.gov, through a paper enrollment form, by calling the plan, or by calling 1-800-MEDICARE. (1-800-633-4227). TTY users call 711, 24 hours a day, 7 days a week.

Q. What does a plan’s Overall Star Rating mean?

A. The Overall Star Rating combines scores for the types of services that each plan offers. For plans covering health services, it measures the overall score for quality of those services and covers many different topics within five categories. For plans covering drug services, it measures the overall score for quality of those services and covers 15 different topics in four categories. To view more information on the Overall Star Rating, visit www.medicare.gov.

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.