To help you make a more informed decision, the following sections answer some of the questions you may have about Medicare Part D and Express Scripts Medicare.
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.
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.
There are three main costs associated with standard Medicare Part D prescription drug coverage:
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.
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.
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.*back to top
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.
Here are some key points to consider to help you get true value from your Medicare Part D plan:
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.
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.
You can enroll in a Medicare Part D plan during these times:
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:
Note: If you get Extra Help, you won't have to pay a late enrollment penalty.
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).
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:
Express Scripts Medicare offers three different plans to meet your individual needs:
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.
You can also get a complete list of covered drugs by downloading the formulary you want to review:
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.
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.