Tips & Resources for Prescription Drug Coverage

Understand how Medicare drug plans work to set proper expectations for enrolling and utilizing your plan.

• Are My Prescription Drugs Covered & What Rules May Apply? →

  Verify your medications are covered next year and what rules may apply.

  1. Are your medications in the plan’s formulary (list of medications)?

  2. Check tier, prior authorization (PA), step therapy (ST), and quantity limits (QL).

  3. Explore pricing using different brands of retail pharmacies and a plan’s preferred mail-order.

  4. Review how these costs apply before you reach the calendar year cap for covered medications ($2,100 in 2026).

  5. Add plan premiums and costs for covered medications at the pharmacy for total estimated cost of medications on the plan.

  6. All plans offer the Medicare Prescription Payment Plan (M3P) that allows you to spread out payments through the remainder of the year.

• How can two people pay such different prices for the same medication at the same pharmacy? →

  Tiering varies by plan. Even if a drug is expensive, each Medicare Part D plan sets its own tiers.

  • One plan may put a drug in Tier 3 (preferred brand)

  • Another may put it in Tier 4 (non-preferred)

  • Another may classify it as specialty tier

  Deductibles, copayments and coinsurance are plan-specific and also impact how two people taking the same medication might have very different out-of-pocket costs depending on their plan.

• Utilization Controls Often Apply to High-Cost Drugs →

  Medicare drug plans may have rules that determine if and how the Part D or MAPD may cover drugs. These rules can be called:
  
  🔹Prior Authorization
  Your doctor must get approval from the plan before the plan will cover the medication. Used a lot for: expensive drugs, specialty drugs, or medications with safety risks.

  🔹Step Therapy
  You must first try a lower-cost or preferred medication before the plan will cover a more expensive version.

  🔹Quantity Limits
  The plan limits how much of the drug you can get at one time (e.g., 30 pills per 30 days).

  🔹Medication safety checks, drug management programs. Plans check for:
  Dangerous drug interactions
  Opioid safety
  Duplicate medications
  High-risk prescribing
  These are automatic safety systems.
  
  Quote systems, plan documents such as plan formularies (lists of medications) outline some of these controls.

• What if I don't take any expensive medications...will the cheapest Part D plan ? →

  Explore adding an expensive medication to the plan.
  
  Don’t know of any? Do a search for some expensive medications then add them to your search to see how the plan searches vary.

• What pharmacies can I use? →

  Per Medicare.gov you can choose where to fill your prescriptions, but using certain types of pharmacies might save you money. Some pharmacies may offer a 2- or 3-month supply of covered drugs.

  🔹 In-network

  🔹 Preferred in-network

  🔹 Mail-order

  🔹 Out-of-network pharmacies

• Resources for choosing a stand-alone Part D plan →

  🔹 Medicare drug coverage costs explained.

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• New Item →

  Medicare drug plans use tools to control cost and ensure safe, appropriate use. These rules apply no matter what drug tier you’re on.

  🔹 Prior Authorization

  Your doctor must get approval from the plan before the plan will cover the medication.
  Used a lot for: expensive drugs, specialty drugs, or medications with safety risks.

  🔹 Step Therapy

  You must first try a lower-cost or preferred medication before the plan will cover a more expensive version.

  🔹 Quantity Limits

  The plan limits how much of the drug you can get at one time (e.g., 30 pills per 30 days).

  🔹 Medication Safety Checks / Drug Management Programs

  Plans check for:

  • Dangerous drug interactions

  • Opioid safety

  • Duplicate medications

  • High-risk prescribing

  These are automatic safety systems.

• Safely Shop Stand-alone Part D Plans on Medicare.gov →

  🔹 Medicare.gov
  🔹 Call 1-800-MEDICARE
  ‍ ‍ TTY Number: 1-877-486-2048

• Shop Medicare Advantage Plans that include Part D with Shawn Marie →

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