Ask the Pharmacist: Part D Changes*

Understanding your prescription drug coverage is an important part of managing your health and your budget. Medicare Part D can feel complex, especially with yearly changes and different coverage options. Below are answers to some common questions to help you better understand your benefits and make informed decisions about your medications.

Medicare Part D: Frequently Asked Questions

Q: What is Medicare Part D?
A: Medicare Part D helps pay for outpatient prescription drugs, such as pills and injectables you take at home, many name-brand and generic drugs and some vaccines (shingles, for example). Part D usually does not include drugs given during a hospital stay (Part A or B) or over-the-counter medications, such as pain relievers or vitamins.

Q: Why did my Part D coverage change this year?
A: Your coverage may change annually. Changes to your coverage are communicated in the Annual Notice of Change (ANOC), and complete coverage details can be found in your Evidence of Coverage (EOC).

Q: Could you explain the prescription drug tier system and how I find in what tier my drugs belong? 
A: Our current tier structure looks like this:

Tier 1: Preferred Generics
Tier 2: Generics
Tier 3: Preferred Brands
Tier 4: Non-Preferred Drugs
Tier 5: Specialty Drugs  

You can search the formulary to find the tier that your drug lands in. Typically, the higher the tier, the higher the cost. To see the cost for each tier, consult your EOC. To make things easier, you can also search for your drugs online to see the cost in real time. This tool also lets you search for alternatives that might make your drugs cheaper.

Q: I've been hearing about changes to Medicare drug pricing. Will these changes affect my prescription costs?
A: Medicare has recently started working to lower the cost of certain high-cost medications through manufacturer maximum price negotiations. This change applies to select medications and may not impact everyone but can lower the out-of-pocket cost for patients taking the impacted drugs.

Recent changes in Medicare added protections for consumers. These protections include the elimination of the coverage gap, also known as the "donut hole", so there are no sudden mid-year cost spikes.

The changes also included a significant reduction to the yearly maximum amount a patient will pay out of pocket for their prescription medications. Once the maximum is reached, you pay $0 for covered drugs for the rest of the year. These changes are meant to give you more protection, more predictability and fewer surprises, especially if you ever need expensive medications.

Prescription costs are influenced by several factors, including how medications are priced and how your specific plan is structured. Because of that, what you pay can vary by medication, pharmacy and plan. Always refer to your Evidence of Coverage (EOC) and plan-specific formulary for specific coverage details.

Q: What are some ways that I can save money on my prescriptions? 
A: Ask about generics and biosimilars; they work the same as brand-name drugs and reference products but usually cost much less. 

Additionally, know your limits. In 2026, Medicare Part D has a $2,100 yearly out-of-pocket cap. After you reach it, you pay $0 for covered drugs the rest of the year. 

Some pharmaceutical companies offer programs to help pay for prescriptions for people in a Part D plan. Use the Pharmaceutical Assistance Program search tool on Medicare's website to search your drug(s) and find out if there is an assistance program available.

Finally, compare plans yearly; review your coverage during Open Enrollment to be sure your medicines are covered at the lowest cost.

Q: What is the best way to prepare and plan for my drug costs? 
A: We encourage all members to read their ANOC every year to understand what is changing in their plan. The drug search tool found on our website is also helpful in estimating specific prescription drug costs and comparing those costs at your preferred pharmacies.

Q: Why should I enroll in the 90-day mail order program with CVS? 
A: The mail order program helps you stay on track with your prescription refills so you don't run out of your medication and potentially helps you save on costs. 

*Not all plans include Part D.