What is the “Doughnut hole” in Part D Medicare coverage, and how does it work?
The donut hole no longer exists in Medicare Part D as of 2025. Previously, beneficiaries would enter a coverage gap after reaching a certain spending limit on prescriptions. In that phase, they paid a larger share of drug costs until reaching catastrophic coverage. Starting in 2025, a new out-of-pocket cap replaced the old donut hole […]
What if I need a drug that isn’t on the Medicare Formulary or costs too much?
If your physician determines that you need a drug that is not on a Part D plans formulary, they can ask the insurance company for an exception. However, there are rarely drugs that are not on the formulary that an insurance plan will grant an exception for. In most cases, these are experimental drugs that […]
What is a “formulary” in Part D Medicare?
Every Part D plan has a list of covered drugs called a formulary. Medicare provides insurance companies that sell Part D plans guidelines for the classes of drugs they have to cover but does not always specify the exact drugs that must be included on the formulary. Medicare excludes some drugs from their list of […]
I already have drug coverage through the VA. Do I still need to sign up for Part D Medicare?
In most cases, if you have drug coverage through the VA, the benefits are considered creditable by Medicare. This means that as long as you are enrolled in VA drug coverage, you don’t have to enroll in a Part D drug plan to avoid incurring a late enrollment penalty if you ever do need or […]
What does a Medicare drug formulary with tiers mean?
Every Part D plan has something called a formulary, which is a list of drugs covered under the plan. Each formulary has a set of tiers, and in most cases, Part D plans have between three and six tiers. A lower-tier drug usually has lower copays or coinsurance than a drug in a higher tier. […]
If I sign up for Part D during Medicare enrollment, how soon does the coverage start to take effect?
When you sign up for a Part D plan, the date the coverage becomes effective depends on which enrollment period you used to sign up for your Part D plan. – If you sign up for a Part D plan during the Annual Enrollment Period, which runs from October 15th through December 7th, your coverage […]
I am covered by Medicare, but I don’t take any medications. Is it necessary to sign up for a drug plan?
You’re not required to enroll in a Medicare Part D drug plan when you first become eligible, but if you delay and don’t have other creditable drug coverage, you could face a late enrollment penalty when you do sign up. The penalty applies if you go 63 or more days without Part D or creditable […]
What’s the late enrollment penalty for Medicare Part D, and when does it take effect?
Suppose you don’t enroll in a Part D prescription drug plan or a Medicare Advantage plan that includes Part D coverage when you are first eligible for Medicare. In that case, you may be assessed something called the Part D late enrollment penalty. The late enrollment penalty is an amount is added to your Part […]
Will a Medicare Advantage plan cost me more if I have a pre-existing condition or if I smoke?
The short answer is no. Medicare Advantage plans are not allowed to medically underwrite, which means they cannot charge you more or decline your coverage for any pre-existing condition. They also cannot charge you more if you are a smoker. In fact, they are not allowed to ask you any health questions when you are […]
Are covered benefits and cost-sharing requirements under Medicare Advantage plans the same thing?
Covered benefits and cost-sharing for Medicare Advantage plans are two very different things. Covered benefits are a list of specific services, tests, etc., that are covered by your Medicare Advantage plan. All Medicare Advantage plans must cover at a minimum the same benefits provided by Original Medicare Parts A & B. They also frequently include […]