Medicare Part D is prescription drug coverage that is available to everyone with Medicare. Even if you don't take a lot of medications now, you may still want to join a Medicare Part D plan for protection against higher drug costs in the future.
To get Medicare Part D prescription drug coverage, you must join a plan offered by an insurance company or other private company approved by Medicare. You must also be a U.S. citizen or lawfully present in the United States.
Each Medicare Part D drug plan has its own list of covered prescription drugs called a formulary. It's important to check a plan's formulary to see if your medications are covered by the plan. Learn more about covered drugs.
Medicare requires all Part D plans to cover at least two drugs in each therapeutic drug category. Certain types of drugs are not covered by Medicare Part D.
|These items are covered||These items are not covered|
|Drugs that promote fertility|
|Drugs for the relief of coughs and colds|
|Drugs for cosmetic purposes or hair growth|
|Prescription vitamins and mineral products, except as noted within the plan's formulary|
|Drugs for sexual or erectile dysfunction (ED)|
|Drugs for anorexia, weight loss or weight gain|
|Certain outpatient drugs|
In general, you must use pharmacies that are in the plan's network for your drugs to be covered. There are exceptions, such as in an emergency. In most cases, if you use a network pharmacy, you will not need to submit a claim form.
Network pharmacies include retail pharmacies and, in some cases, a home delivery pharmacy, such as Express Scripts Pharmacy®.* For some plans, there may be additional savings if you take advantage of preferred retail pharmacies or preferred home delivery.
If you are new to Medicare, it's important to enroll in a Medicare Part D plan as soon as you become eligible (during your Initial Enrollment Period) to avoid paying any late enrollment penalties.
If you are already enrolled in a Medicare Part D plan, you can generally switch plans only during the Annual Enrollment Period, which runs from October 15 through December 7 each year.
Note: Some people, such as those who also receive Medicaid, may be allowed to enroll at other times of the year without penalty.
As a member of a Medicare Part D plan, you will pay a monthly premium in addition to any premiums you pay for Medicare Parts A and B. You may also be responsible for paying part of your prescription drug costs. Your actual drug plan costs will vary, depending on the following criteria:
Compare plans and see your costs based on where you live, the drugs you take and the pharmacy you use.
Drug costs vary throughout a plan year based on your current stage of coverage. The following information is for the 2021 plan year:
There is no deductible for Tiers 1, 2 or 6.
$445 per year for Tiers 3, 4 and 5 only.
There is no deductible for Tiers 1 or 2 or select drugs on Tier 3.
$285 per year for Tiers 3, 4 and 5 only.
There is no deductible for Tiers 1, 2, 3 or 6.
$100 per year for Tiers 4 and 5 only.
Unless your Medicare Part D plan provides some coverage in the Coverage Gap:
Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you could get help paying for any Medicare drug plan's monthly premium, yearly deductible, and prescription drug copayments or coinsurance. This Extra Help also counts toward your out-of-pocket costs.
To see if you qualify for getting Extra Help, call:
If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium, deductible and drug costs may be lower. When you join Express Scripts Medicare, Medicare will tell us how much Extra Help you will get. Then we will let you know the amount you will pay. To see what your monthly premium would be if you qualify for Extra Help, please see the attached chart.
In some cases, you may not get the full amount of Extra Help you deserve because your income status information is out of date. Under the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy, if you show proof that you qualify for additional Extra Help, the plan sponsor must adjust the amount that you pay.
For more information on the BAE policy, please visit the CMS website at:
If you are enrolled in both Medicaid and Medicare (often called dual eligible), you qualify for Extra Help automatically. You, your pharmacist, advocate, representative, a family member, or another person acting on your behalf may submit any one of the following items as proof that you are eligible for both Medicare and Medicaid:
A copy of the award letter you received from the Social Security Administration (SSA) stating that you qualify for Extra Help may be submitted by you, your pharmacist, advocate, representative, a family member, or another person acting on your behalf.
You or your pharmacist may submit any one of the following items as proof that you qualify to pay $0 toward your drug benefit:
Please fax documents to:
Express Scripts Medicare (PDP)
If you have any questions, please call Customer Service toll free at the numbers on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week, except Thanksgiving and Christmas.
For general information about Medicare programs, please refer to the following Centers for Medicare & Medicaid Services (CMS) and Social Security Administration resources: