WELCH INSURANCE

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Medicare Part D

The prescription drug benefit is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with your Medicare Advantage Plan.

Unless you have creditable drug coverage and will have a Special Enrollment Period, you should enroll in Part D when you first get Medicare. If you delay enrollment, you may face gaps in coverage and enrollment penalties.

How Prescription Drug Coverage Works in 2026

Yearly Deductible

$0 – $615

The member pays all

Plan pays nothing

Initial Coverage

$2,100

That the Member pays

Catastrophic Coverage

After you pay $2,100 You pay nothing for prescriptions.

Typical Tiers for Part D Formularies

  • Cost-Sharing Tier 1: Preferred Generic
    Tier 1 is the lowest tier. Low cost preferred generic drugs are included in this tier.

    Cost-Sharing Tier 2: Generic
    Tier 2 includes preferred generic drugs.

    Cost-Sharing Tier 3: Preferred Brand
    Tier 3 includes preferred brand drugs and non-preferred generic drugs.

    Cost-Sharing Tier 4: Non-Preferred Drug
    Tier 4 includes non-preferred brand drugs and non-preferred generic drugs.

    Cost-Sharing Tier 5: Specialty Tier
    Tier 5 is the highest tier. It contains very high-cost brand and generic drugs, which may require special handling and/or close monitoring.

Medicare Part D has formularies,

Each Part D plan has a list of covered drugs, called a formulary. If your drug is not on the formulary, you may have to request an exception, pay out of pocket, or file an appeal.

Medicare Part D has drug categories

A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. 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.

You purchase Part D in addition to Parts A and/or B.

You have two choices; a stand-alone Medicare Prescription Drug Plan (PDP) or a Medicare Advantage Plan that comes with prescription drug (Part D) coverage. You can only have one Part D drug plan.

Medicare Part D may have preferred pharmacies

Some Part D plans have preferred pharmacies where you can receive lower cost for the the same drug at other pharmacies.

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Have any questions?

Check our FAQ

  • There is no cost to using a broker.
  • A broker can compare many companies and plans and explain the differences to you. A company agent only knows their plans and can only offer their plans.
  • A broker continues as an advisor to you. If your health changes and plans premiums and benefits change a broker can keep you current.
  • If you have questions or issues, your broker is an additional asset that you can rely on and understands the plan you are on.
  • Initial Enrollment Period (IEP) is when you are newly eligible for Medicare because you are turning 65. You may enroll during the 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  • Annual Enrollment period (AEP) begins October 15 and ends December 7 of each year. During this period you may switch Medicare Advantage Plans, including one that does offer drug coverage to a Medicare Advantage Plan that does not offer drug coverage. During this period, you may join a Medicare Prescription Drug Plan, switch from one Medicare Prescription drug Plan to another Medicare Prescription Drug Plan, or drop your Medicare Prescription drug coverage completely.
  • Special Enrollment Period (SEP) is for special circumstances such as, losing your employer coverage, moving to a new service area, or if you are receiving government monetary assistance.

Yes, if you have a Medicare Supplement Plan with an insurance company you can purchaser a Part D drug plan from any company that offers it in your service area.

You can apply online by copying and pasting:

https://secure.ssa.gov/iClaim/rib 

Or call Social Security at: 800-772-1213

Prescription drug coverage is creditable if the value of the coverage equals or exceeds the value of standard prescription drug coverage under Medicare Part D, in accordance with Centers for Medicare and Medicaid Services (CMS) 

The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage.