Medicare Prescription Drug FAQs
1. How your Initial Deductible affects what you pay for formulary drugs.
2. Reminder: What to do if your prescription is not covered by your 2024 Medicare drug plan.
1. How your Initial Deductible affects what you pay for formulary drugs.
Question: How does the Part D Initial Deductible work? I use a drug with a $43 copay, but the pharmacy charged me $350.
If your Medicare Part D plan has a deductible (the standard 2024 Medicare Part D deductible is $545), you must pay the deductible before your Medicare plan coverage begins to pay a share of the retail drug cost – unless you are purchasing:
– a lower-cost medication excluded from your plan’s deductible,
– an insulin product covered by your Medicare plan, or
– a Medicare covered ACIP recommended vaccine.
Finally, you will receive immediate coverage of all formulary drugs when your Medicare drug plan has a $0 deductible.
Example 1 – What do I pay when my first purchase of the year is a $390 Tier 4 drug and I have a $545 deductible?
You will pay $390. If you have a Tier 4 formulary medication that costs $390 (retail) and your Medicare plan has a $545 deductible, you would pay the full retail cost of $390 and you would have a remaining deductible balance of $155 ($545 – $390) that you must pay before your plan’s cost-sharing coverage begins.
Example 2 – What will I pay when my first purchase of the year is a $37 Tier 2 drug excluded from my deductible?
You will pay your plan’s Tier 2 copay. Many 2024 Medicare Part D plans exclude Tier 1 and Tier 2 drugs from the plan’s deductible – and these low-cost drugs receive immediate coverage. So, if you have a $545 deductible with Tier 1 and Tier 2 drugs excluded, and you purchase a Tier 2 generic that has a retail price of $37 (with a copy of $6) – you pay only the $6 copay and your $545 deductible is not affected.
Example 3 – What do I pay for a $750 Tier 3 drug that is more expensive than my Part D plan’s $545 Initial Deductible?
Around $592. When you purchase a drug with a retail price higher than the balance of your deductible, your cost would split across (or “straddle“) two or more phases of your Part D coverage. You first pay the deductible balance and then you would pay all or a portion of your Tier 3 copay for the remainder of the retail price that falls into your Initial Coverage phase.
So, if your Medicare Part D plan has a $545 deductible and you purchase a $750 Tier 3 drug that has a $47 copay, you would first pay the $545 deductible and the remaining amount of the retail price or $205 ($750 – $545) would carry-over into your Initial Coverage phase where you have a $47 copay on the $205 balance.
In the end, your total cost for this first purchase of a $750 Tier 3 drug would be $592 ($545 + $47).
Example 4 – What do I pay for a $15,175 Tier 5 specialty drug when I have a $545 Initial Deductible?
Around $3,333. Your coverage cost in this example would be calculated like the straddle claim in Example 3, above. However, if you are using any brand-name medication with a retail cost over $12,051, having a 25% cost-sharing, you will move through (or straddle) all four phases of your drug coverage with a single purchase: you will satisfy your $545 deductible, enter and exit your Initial Coverage phase, then enter and exit the Donut Hole, and finish in the Catastrophic Coverage phase (where, starting in 2024, you will have $0 cost-sharing).
The total cost of your first $15,175 purchase would be around $3,333 calculated as: $545 deductible + $1,121 in initial coverage phase + $1,667 in the Coverage Gap + $0 in the Catastrophic Coverage phase. Again, once reaching the 2024 Catastrophic Coverage phase, you will have no cost-sharing ($0) for formulary drugs through the end of the year.
Example 5 – What do I pay for Tier 3 Insulin when I have not met my Part D plan’s $545 Initial Deductible?
No more than a $35 copay. Just as in 2023, all 2024 Medicare drug plans offer all insulin on the plan’s formulary at a copay of no more than $35 based on the Inflation Reduction Act. If you are still in the deductible phase, you will pay a copay of no more than $35 even though you have not met your plan’s $545 initial deductible – and your insulin purchase will not affect your $545 deductible.
2. Reminder: What you can do when one of your prescriptions is not covered by your 2024 Medicare drug plan.
During the first 90 days of your plan coverage, you can ask your Medicare prescription drug plan for a one-time, transition fill (a temporary 30-day supply of your medication). To initiate a transition fill request, call the Member Services telephone number found on your Member ID card.
Question: How much will I pay for a transition fill of a non-formulary drug?
Usually 25% to 50% of retail. Your Medicare Part D plan will charge you the same cost-sharing as if your formulary exception request was granted and your non-formulary drug is being covered by your 2024 plan. For example, if your Medicare Part D plan agrees to cover a non-formulary drug, you may be asked to pay the cost-sharing of a Tier 4 Non-Preferred drug. You can use our plan search tools (PDP-Finder.com or MA-Finder.com) to see your plan’s cost-sharing for all tiers and phases of coverage.
Question: Will I receive a transition fill of a non-formulary drug even though I was enrolled in a different Medicare Part D plan last year?
Yes. A transition fill is available to all Medicare plan members who were previously using a medication, even new members.
Question: How long will I have to get my transition fill?
90 days. Your 30-day supply transition fill is usually only available for the first 90 days of your Medicare drug plan coverage. If you live in a long-term care (LTC) facility, then you are granted a 91-day transition fill that may extend over a longer period.
Question: Is it possible to get an extension for my transition fill?
Maybe. Your Medicare Part D plan may provide you with a transition fill extension, however, such an extension is provided only on a case-by-case basis in exceptional situations such as when you have filed a formulary exception request that has not been fully processed by the end of your transition fill period.
Question: I just started using a new medication in 2024 and it is not on my plan’s formulary, can I still get a transition fill?
This is not the intent of the transition fill policy. Transition fills are for medications that you were using previously and that are no longer covered by your new Medicare Part D plan (or now have drug usage management restrictions). Instead of a transition fill, you should initiate a formulary exception request for coverage of your non-formulary drug. The Centers for Medicare and Medicaid Services (CMS) notes that the “purpose of the transition policy is to address situations when an enrollee’s ongoing drug therapy (whether the Part D sponsor is able to actually ascertain ongoing therapy or not) could be potentially interrupted by a drug being non-formulary”.
Question: Can I get a transition fill if I used a medication last year that is no longer covered by the Medicare Part D program?
No, unless the non-Part D drug is used for a medically-accepted indication. Specific medications are excluded from the Medicare Part D program (such as weight-loss drugs) or sometimes medications are removed from the market due to FDA health and/or safety concerns. Usually, you cannot get a transition fill for a drug excluded from the Medicare Part D program or a medication that was removed from the marketplace.
As an example, the brand-name drug Ozempic is covered by many Medicare drug plans for the treatment of diabetes, but is not covered by Part D as a weight-loss drug.
Question: If my medications are now subject to drug restrictions (such as prior authorization), is it possible to get a transition fill while requesting a formulary exception?
Yes. According to CMS, the transition fill policy will apply to both non-formulary Part D drugs and “Part D drugs that are on a sponsor’s formulary but require prior authorization or step therapy or that have an approved [quantity limit] lower than the beneficiary’s current dose, under a plan’s utilization management requirements”.
Please remember, transition fills for controlled drugs, such as opioids, may have additional Medicare restrictions.