Prescription drug coverage

There are 2 ways to get prescription drug coverage through Medicare, either by a stand alone Drug plan or through a Medicare Advantage plan with drug coverage.  To get Part D you must have and/or be eligible for Part A and B.  Prescription drug plans cover drug purchased through a retail pharmacy or mail order pharmacy.

Like Part B, there is a penalty for not taking Part D when first eligible.  That penalty is 1% per month you go w/o a drug plan until you enroll in one for the average cost of a drug plan (Approx. $35.00 monthly).
**Example not enrolled for 12 months .35 x 12 = $4.20.

Also, the IRMAA applies to Part D as well, get the upcharges here. View IRMAA

All Part D drug plans have to follow rules set by Medicare.  RX Plans have to carry 2 drugs minimum in each family of their formulary* for a particular condition.  All Part D plan are subject to various "Enrollment Periods"  For a list click here.  Every drug plan works on a tiered system of pricing there are up to 6 tiers to drug plans available in our area.

Drug Plan Tiers:

  1. Tier 1 is Preferred Generic
  2. Tier 2 Non-Preferred Generic
  3.  Tier 3 Preferred Name Brand
  4.  Tier 4 Non-Preferred Name Brand
  5.  Tier 5 Specialty Drugs (Medicare defines any drug for which the negotiated price is $670 per month or more, as a specialty drug which is placed in a specialty tier that requires a higher patient cost sharing.)
  6. Tier 6 drugs are available on select drug plans.

Every Drug Plan has 4 "Stages" works on a calendar year.

  1. Deductible (if applicable) once you pay the deductible you go to the Initial Coverage Stage
  2. Initial Coverage Stage, after you paid the deductible then you pay a straight co-pay/co-insurance for your drugs up to a retail cost limit of $4330.00 for 2022 / $4,660.00 for 2023.
  3. Coverage Gap (donut hole) once you've exhausted the $4330.00 retail cost limit in the Initial Coverage Stage you go into the Coverage Gap (donut hole) and will pay 25% of the costs for name brand drugs and 25% of the costs for generics until you hit another retail cost limit of $7,050.00 for 2022 / $7400.00 for 2023. After reaching $7,050.00 you move into the Catastrophic Coverage for the remainder of that calendar year.
  4. Catastrophic Coverage In this stage you pay $3.95 in 2022 / $4.15 for 2023 for generics and $9.85 in 2022 / $10.35 in 2023 for name brand drugs or 5%.

*It is very important that you do and annual review of your prescription drug plan as the plan can change drugs in and out of a formulary and once December 7th passes you are locked into the plan you are on until next open enrollment (October 7th thru December 7th)​​​

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Chapman Insurance Group, LLC, Medicare, Lenoir City, TN

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact or 1-800-MEDICARE to get information on all of your options.”