Understanding Medicare Part D Costs

Medicare Part D is a medication insurance program administered through private insurance companies. It’s essential to know Part D has:

• different levels of coverage and costs.
• a specific list of drugs available for each plan.
• a list of in-networkIn-network refers to the doctors, hospitals and other providers that are inside of your provider network. A provider network is a group of providers that have agreed with your health insurance company to treat its customers. pharmacies that you are required to use after enrollment.

You pay a monthly premium for prescription drug coverage in addition to your Medicare Part B premium. The average Part D premium in 2021 is $33.06, though the cost can vary with different plans. ^[i]

Part D costs depend on:

• The prescription drugs you need
• The plan you join 
• Whether you use a pharmacy in your plan’s network
• Whether the drugs you use are on your plan’s formulary
• Whether you’re eligible for Extra Help (a financial assistance program)

Other costs to consider:

• Medicare Part D monthly premiums
• Medicare Part D annual deductibles
• CopaymentsA copayment is the fixed amount you pay directly to your provider for medical services or prescription drugs covered in your plan. For example: If your plan includes a copayment of $20 for office visits, you'll pay $20 to your doctor whenever you have an appointment. or co-insuranceCoinsurance is the percentage of your medical costs that you pay after you meet your deductible. Your insurance company pays the remaining amount. For example: If you have a $1,000 medical bill and your coinsurance is 20%, you'll pay $200. Your insurance company will cover the final $800.
• Late enrollment penalty

Your income plays a role in determining your Part D premium. You’re required to pay more for your prescription drug plan if you made more than $88,000 as an individual or $176,000 as a couple when filing your most recent tax return. The calculation is known as the income-related monthly adjustment amount (IRMAA).Income-Related Monthly Adjustments determine the premium costs for Medicare Part B and Part D based on your income. 

Medicare Part D plans have different levels of “tiers,”Drug tiers are the categories health insurance companies use to categorize all the prescription drugs they cover. Drug tiers typically range from One to Five; Tier One is the lowest and usually includes the least expensive generic drugs. Tier Five includes specialty drugs that are usually very expensive. Some carriers have a Sixth Tier. which determines the cost of certain prescription drugs on the plan’s formulary list.A formulary is a list of prescription drugs covered by a specific prescription drug plan. Medications that fall into the first tier have the lowest copays or copayments. The price goes up with each tier.  

• Tier 1 has the lowest copay for generic drugs. To receive approval from the Food and Drug Administration, generic drug makers must prove that their product performs the same way as the corresponding brand name drug. Generic drugs use the same active ingredients as brand name drugs to achieve desired results.
• Tier 2 has a medium copay for preferred brand name drugs. Preferred brand name drugs are medications manufactured by one manufacturer that are typically lower-cost among all brand name drugs. This is partly because these medications have been in the market for some time and are widely accepted).
• Tier 3 has a higher copay for preferred brand and non-preferred brand name drugs. Non-preferred brand name drugs, on the other hand, tend to cost more because they are new to the market. You may have heard the term “designer drugs.” These high-cost drugs fall into the same category.
• Tier 4 has a higher copay for non-preferred brand drugs and non-preferred generic drugs.
• Tier 5, or the Specialty Tier, has the highest copay. It contains very high cost brand and generic drugs, which may require special handling and/or close monitoring.

Medicare Part D Payment Stages

There are four stages of costs for Medicare Part D. You’re responsible for paying different amounts in each stage.

1. Stage 1 annual deductible
2. Stage 2 initial coverage
3. Stage 3 coverage gap, or “donut hole”
4. Stage 4 catastrophic coverage.

You should be aware of Medicare Part D’s lifetime late enrollment penalty if you miss the Initial Enrollment Period. The penalty applies if you go for more than 63 days after your Initial Enrollment Period without creditable drug coverage.

The late enrollment penalty cost is calculated by Medicare when you enroll in a Part D plan. To calculate the penalty,  multiply 1% of the yearly average premium (which is $33.06 in 2021) by the number of eligible months you did not have Part D insurance. Then, you round to the nearest ten cents. 

Example: Let’s say your Initial Enrollment Period ended March 31, 2018. You waited until December 2020 to join a Part D plan during the Open Enrollment Period. Your policy went into effect on January 1, 2021, which means you went 21 months without creditable coverage.

Here’s how to calculate the penalty:

.21 (multiply 1% by the number of months you went without coverage even though you were eligible to enroll) X $33.06 (2021 average Part D premium) = $6.90 ($6.94 before rounding to the nearest $.10)

The cost of the penalty can change if the national premium average increases or decreases. A late enrollment penalty can remain in effect as long as your Part D plan is active.

Do you have more questions about enrollment and how to avoid the penalty? Check out our guide on how to navigate Medicare Part D enrollment.

Medicare offers a program called Extra Help to assist with Part D costs for those with limited income and resources. Extra Help is estimated to be worth $5,000 per year. ^[i] If you qualify, the program helps cover your premiums, deductibles and co-insurance costs.

Extra Help Eligibility

To qualify for Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia. If you’re not sure if you are eligible based on income or resources, you can apply.

Ways you can automatically qualify for Extra Help:

• You already qualify for Medicare and MedicaidMedicaid is a state-based health insurance program for individuals that qualify. Unlike Medicare, Medicaid does not have age restrictions for members. 
• You are enrolled in a Medicare Savings Program 
• You already receive Supplemental Security Income (SSI) benefits

You’re eligible for Extra Help if both apply:

• Your resources are limited to $14,790 for individuals or $29,520 for couples. Resources include savings, investments, real estate outside of a primary residence, stocks and more.
• Your annual income is limited to $19,140 for individuals or $25,860 for couples.

How to Apply for Extra Help

If you don’t automatically qualify but meet the limited requirements listed above, you can apply for Extra Help online TRUSTED & VERIFIED ssa.gov , by telephone (1-800-772-1213) or by visiting your local Social Security office. You will need bank account statements, investment statements, stock certificates, tax returns, pension award letters and payroll slips.