Medicare Part D - What Should I Ask About Prescription Drug Plans?

Medicare Prescription Drug Plans (abbreviated as PDP) and also known as Medicare Part D can be confusing when shopping for a plan you feel best suits your needs. Part D is offered through private insurance companies either as a stand alone PDP or could be included in a Medicare Advantage plans that includes prescription drugs. (MAPD).

Below are some the items I recommend you do or ask before enrolling in a drug plan:

  • Make a complete list of all the prescription drugs you take, with the exact spelling of each drug, the dosages of each drug, and how many times a month you take each drug.

  • Determine which pharmacy you plan to use and if you are dead set on only using that particular pharmacy chain. Or if you would be willing to go to another pharmacy, if your costs were lower for your drugs at a different pharmacy. (Copays/Coinsurance can vary from pharmacy to pharmacy depending on the specific plan you choose and which pharmacies are considered “Preferred" pharmacies within your plan’s pharmacy network.)

  • After that find out if all your drugs are in the plan’s formulary. (A formulary is a list of drugs that are covered in that specific plan.)
    Note: Keep in mind each “specific" plan can have their own formulary. There can be different formularies for each “specific" drug plan, even if plans are with the same insurance company. Also Tier levels for each “specific" plan can be different. So it is important to check with each plan you are considering, whether your drugs are in that “specific" plan’s formulary and what the costs are for each of your drugs.)

  • Does the drug plan impose any coverage restrictions?
    Some restrictions could be:
    1) Prior Authorizations
    2) Step Therapy
    3) Quantity Limits

  • What happens if the plan doesn’t cover a drug I take, does it cover a similar one that will work for me?

  • As I mentioned above, find out how much you will be paying for each drug at the pharmacy or mail order. (Understand what the Tier levels are and the costs you are responsible for each of your drugs within the plans you are considering.)

  • What are the monthly premiums for the drug plan?

  • How much is the annual deductible? Also what Tier levels fall into that category that requires an annual deductible?

  • Understand what the coverage gap (also known as the Donut Hole) is and how it will affect your costs during each year.

  • Check with your doctor to see if you can take a less expensive drug that will do the same thing. (Brand vs. Generic)

  • If you have a low income, see if you are eligible for Extra Help or a State Pharmaceutical Assistance Program.

  • What is the service area for the drug plan you are considering?
    (What if you move out of the service area?)
    What is my network of Pharmacies?
    (What if I go out of network?)

  • Again, understand which pharmacies are “Preferred” pharmacies. Since those are the pharmacies that you will be paying less for your drugs.
    (Note: Some plans do not have Preferred Pharmacies)

Conclusion: One drug plan doesn’t fit all. A drug plan that may cost you the least in annual out of pocket expenses, may be totally different for somebody else with different drugs. The out of pocket costs will based your the specific drugs you take (tier levels of the drugs you take), the pharmacy you go to, etc.
You can go to, put in your zip code, all the drugs you take along with doses, frequency you take them, pick pharmacies you plan to use and it will estimate your out pocket expenses including premiums. It should list the least expensive plan at the top of the web page search results. Also make sure to consider the star ratings of the plan you choose before enrolling.

Note: Medicare Insurance information can be overwhelming and confusing to many people. As an independent licensed agent I can explain things to you in simple terms so you feel comfortable making a decision. Then I can help you choose and enroll in a plan that you feel fits your needs.

By the way, it doesn’t cost you any more if you enroll in a Medicare Insurance plan through me as an independent agent versus directly with an insurance company either over the phone or via the Internet, since I get paid by the insurance companies for your enrollment. Plus you will have personalized service by a local agent. If you would like my assistance, please call me at 941-404-5334.

By calling this number, I understand I will be directed to a licensed insurance sales agent.

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