What is Medicare Part D and who is eligible for it?

Medicare Part D prescription drug coverage is insurance that covers both brand-name and generic drugs at participating pharmacies. Everyone with Medicare is eligible for this coverage.

To get Medicare Part D prescription drug coverage, you must join a plan provided by an insurance company or other private company approved by Medicare. You must also be a citizen or lawfully present resident of the United States. Learn more about Medicare Part D.

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What drugs are covered by Medicare Part D?

Medicare requires all Medicare Part D plans to cover at least two drugs in each therapeutic drug category. Certain types of drugs (such as drugs for weight loss or over-the-counter medications) are not covered by Medicare Part D.

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 Part D drugs.

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How much does Medicare Part D coverage cost?

There are three main costs associated with standard Medicare Part D prescription drug coverage:

  • Monthly premium
    The cost for monthly premiums varies by plan and the state where you live.
  • Annual deductible
    This is the amount you must pay out of pocket before the plan begins covering your drugs.
  • Copayments or coinsurance for your drugs
    This out-of-pocket amount may vary throughout the year based on the coverage stage that you're in.

Learn more about standard Medicare Part D costs.

Compare plans to see an estimate of what Express Scripts Medicare will cost based on where you live, the drugs you take and the pharmacy you use.

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How can I get Extra Help with my prescription drug costs?

If you have limited income and resources, you may qualify for Extra Help to pay for some Medicare Part D prescription drug costs. If you are eligible, Medicare could pay up to 75% or more of your drug costs, including your monthly premiums, annual deductible and copayments or coinsurance.

Many people are eligible for these savings and don't even know it. For more information about Extra Help, contact your local Social Security office or call Social Security at 1.800.772.1213, Monday through Friday, 7 a.m. to 7 p.m. TTY users, call 1.800.325.0778.

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What is the Coverage Gap?

The Coverage Gap, also known as the “Donut Hole,” is the third stage of coverage in the standard Medicare Part D plan. Not everyone will enter the Coverage Gap because their drug costs won’t be high enough. If you reach the Coverage Gap in 2021, this stage begins when your total drug costs (what you pay, plus what your plan pays) exceed $4,130. You remain in the gap until your yearly out-of-pocket drug costs reach $6,550.

In this stage, the amounts you pay out-of-pocket for your covered medications will temporarily change. As part of the standard 2021 Medicare benefit, you will pay only 25% of the cost for a generic drug and 25% of the cost for a covered brand drug while in the gap.*

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What is the Part D Senior Savings Model?

The Centers for Medicare & Medicaid Services (CMS) has a new Part D Senior Savings Model starting with the 2021 plan year. Part D plans participating in the Model will provide beneficiaries with plan choices that offer access to select insulin drugs at a lower out-of-pocket cost. The Part D Senior Savings Model allows Express Scripts Medicare to offer select insulin medications at an affordable and predictable price with our Saver and Choice plans. In the Saver plan, the copay is $35 for a 30-day supply of Tier 3 select insulin medications from any pharmacy in all stages up to the Catastrophic Coverage Stage. As there is no deductible for insulins in Tier 3, the copay will not apply to the plan’s deductible. In the Choice plan, the copay for select insulins in Tier 6 is $0 at a preferred pharmacy or $11 at a standard pharmacy for a 30-day supply in all stages up to the Catastrophic Coverage Stage. View a list of the included drugs.

If you receive Extra Help, you do not qualify for this program, and your Low-Income Subsidy copay level will apply.

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How can I get the most value for my Medicare dollar?

Here are some key points to consider to help you get true value from your Medicare Part D plan:

  • Drug Coverage: Make sure your drugs are covered under the plan's list of covered drugs (formulary). Learn more about drug coverage.
  • Medicare Star Ratings: Choose a plan with an above-average Star Rating from the Centers for Medicare & Medicaid Services, which rates plans for customer service, medication safety, member satisfaction and more. View our Star Ratings.
  • Total plan costs: To find the plan that provides the best value for you, be sure to look at the yearly costs for all your medications in addition to the deductible and monthly premium. Compare plan options.
  • Savings Opportunities: Find a plan that can help you lower your prescription drug costs and delay entering the Coverage Gap by using generics and home delivery.

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Why are Medicare Star Ratings important?

Every year Medicare evaluates plans based on a 5-star rating system. The plans are rated on how well they perform in different categories, including customer service, patient safety, and member experience and satisfaction. The Medicare Star Ratings are important because they help you compare the overall quality of plans. Star Ratings range from 1 Star (poor) to 5 Stars (excellent).

View the Star Rating Report for Express Scripts Medicare.

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Should I choose a plan based on the lowest premium?

Keep in mind that plans with lower monthly premiums could have higher total costs when you consider how much you will pay for your drugs in each coverage stage. Be sure to look at a plan’s total costs, which include the yearly costs for your medications, the deductible and the premiums.

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When can I join a Medicare Part D plan?

You can enroll in a Medicare Part D plan during these times:

  • When you are first eligible for Medicare during your Initial Enrollment Period (IEP).
    Your IEP is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  • During the Annual Enrollment Period between October 15 and December 7 each year.
    Your coverage will begin on January 1, 2021, as long as the plan gets your enrollment request by December 7, 2020.
  • If you are under 65 and eligible for Medicare due to a disability.
    You can join during the 7-month period that begins 3 months before and ends 3 months after your 25th month of disability. You will have another chance to join during the 7-month period that begins 3 months before the month you turn 65 to 3 months after the month you turn 65.
  • If you qualify for a Special Enrollment Period.
    Under special circumstances, you may join or switch plans during a set period of time outside the Initial and Annual Enrollment Periods. In most cases, you have up to 2 months after the month your current coverage ends to join a plan.
  • If you are a dual or other LIS eligible individual, you may qualify for a special enrollment period to enroll in, or disenroll from, a Part D plan once per calendar quarter during the first 9 months of the year.

Learn more about when to enroll in a Medicare Part D plan.

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What happens if I don't join a Medicare Part D plan?

If you choose not to enroll in a Medicare Part D plan when you first become eligible, you may have to pay a penalty if you join later.

You may owe a late enrollment penalty if one of the following statements is true:

  • You didn't join a Medicare Part D prescription drug plan when you were first eligible for Medicare, and you didn't have other creditable prescription drug coverage.
  • You had a break in coverage and didn't have Medicare Part D prescription drug coverage or other creditable prescription drug coverage for 63 or more consecutive days.

Note: If you get Extra Help, you won't have to pay a late enrollment penalty.

Learn more about when to enroll so you can avoid a late enrollment penalty.

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Can I switch plans if I'm already enrolled?

Yes, you can switch Medicare Part D plans once a year during the Annual Enrollment Period (October 15 through December 7, 2020, for the 2021 plan year).

Outside this time period, you may make other changes during the year only if you qualify for a Special Enrollment Period (SEP).

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What is a Special Enrollment Period?

A Special Enrollment Period (SEP) is a certain length of time other than the Annual Enrollment Period (October 15 – December 7) when you may enroll in, or disenroll from, a Medicare Part D prescription drug plan. For example, you may qualify for an SEP for the following reasons:

  • You lose creditable coverage from an employer or other plan sponsor
  • You move to a new permanent address that is not in your current plan's service area
  • Your current plan no longer offers Part D coverage
  • You also receive Medicaid or get Extra Help with Part D costs
  • You are enrolled in a State Pharmaceutical Assistance Program (SPAP)

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Which plans does Express Scripts Medicare offer?

Express Scripts Medicare offers three different plans to meet your individual needs:

  • Our Saver plan offers our lowest premium and low copays.
  • Our Value plan provides more drug coverage and low copays for generics.
  • Our Choice plan has the broadest drug coverage and our lowest deductible.

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Are my medications covered?

Express Scripts Medicare covers the most commonly used prescription drugs in its formularies. When you look up your drugs online, we can even show you if lower-cost medications are available to help you get the most value for your Medicare dollar.

See if your drug is covered and find out which Express Scripts Medicare Part D plan may be right for you based on the medications you take.

Find a Plan

You can also get a complete list of covered drugs by downloading the formulary you want to review:

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Is my pharmacy in the network?

Express Scripts Medicare has a broad network of participating pharmacies, including national chains, local independent retail pharmacies in your neighborhood, and Express Scripts Pharmacy.

See if your pharmacy is in our network and which Express Scripts Medicare plan may be right for you.

Find a Plan

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What advantages does home delivery from Express Scripts Pharmacy provide?

When you activate your home delivery benefit through Express Scripts Pharmacy, you could save money on the medications you take regularly with preferred pricing.

Express Scripts Pharmacy offers the convenience of home delivery with free standard shipping and preferred copays.§ Our registered pharmacists offer 24/7 support by phone to help you with any questions you may have about your medications.

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Need help?

Call 1.866.477.5703 TTY users: 1.800.716.3231
8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas

*Available from manufacturers that agreed to pay a 70% discount on the negotiated price, excluding the dispensing fee and any vaccine administration fee. The plan pays 5%.

Monthly premiums may vary by region.

Other pharmacies are available in our network.

§Standard shipping costs are included as part of your prescription plan.

Express Scripts Medicare’s pharmacy network includes limited lower-cost, preferred pharmacies in rural areas in Alaska; the Saver plan also includes limited lower-cost, preferred pharmacies in suburban areas in Puerto Rico, and the Choice plan also includes limited lower-cost, preferred pharmacies in rural areas in Oklahoma. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call Customer Service at 1.866.477.5703; TTY: 1.800.716.3231, or consult the online pharmacy directory.

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.
Enrollment in Express Scripts Medicare depends on contract renewal.