Prescription medications can be an important part of managing your health, and Medicare Part D is designed to help cover the cost of many prescription drugs. But Part D can be confusing. Who needs it? What does it cover? Is it included with Medicare Advantage? And what happens if you don’t enroll when you’re first eligible? Here’s a straightforward overview from Apple IPA.
Key Takeaways
- Part D is Medicare’s prescription drug coverage, offered through private insurers approved by Medicare.
- With Original Medicare, you can generally join a separate Part D plan.
- Many Medicare Advantage plans include Part D in the same plan.
- Every plan has its own formulary, pharmacy network and costs.
- Going without creditable drug coverage can lead to a late enrollment penalty.
- Review your coverage every year, especially during Open Enrollment.
In This Guide
What Is Medicare Part D?
Medicare Part D is Medicare’s prescription drug coverage.
People with Original Medicare can generally get Part D by joining a separate Medicare prescription drug plan. Most Medicare Advantage plans that offer prescription drug coverage include Part D as part of the plan.
Part D plans are offered by private insurance companies that are approved by Medicare. Each plan can have its own list of covered medications, known as a formulary.
What Does Part D Cover?
Part D generally helps cover outpatient prescription medications that you get from a pharmacy or through certain covered delivery services.
Plans can differ in the medications they cover and how much you pay for them. If you take prescription medications regularly, it can be important to check:
- Whether your medications are covered
- Which pharmacies are in your plan’s network
- Whether your medications have restrictions
- What your deductible and copayments are
- Whether a lower-cost generic or alternative is available
Part D and Medicare Advantage
You may encounter Part D in two different ways.
| Feature | Original Medicare + Part D | Medicare Advantage with Drug Coverage |
|---|---|---|
| How you get Part D | Join a separate drug plan | Included in the plan |
| Health and drug coverage | Two separate plans | Generally one plan |
| Plan rules | Set by the drug plan | Plan networks, formularies and rules apply |
This distinction is important because Medicare Advantage plans can have their own networks, formularies and plan rules.
Key Plan Terms to Know
- Formulary: the plan’s list of covered drugs.
- Premium: what you pay to have the plan.
- Deductible: what you may pay before the plan starts to share costs.
- Copayment or coinsurance: your share of the cost when you fill a prescription.
- Pharmacy network: the pharmacies that work with your plan.
What Changed for Part D in 2026?
One significant change in 2026 is the annual out-of-pocket limit for Medicare Part D-covered prescription drugs. After a person reaches that limit for covered Part D drugs, they pay nothing for those covered drugs for the remainder of the calendar year.
Medicare also began implementing negotiated prices for the first group of selected prescription drugs in 2026. The negotiated prices apply to certain participating Medicare drug plans and covered drugs.
What Happens If You Don’t Enroll in Part D?
If you don’t have Medicare drug coverage when you’re first eligible, you may face a late enrollment penalty if you later decide to enroll.
Generally, if you go 63 days or more without creditable prescription drug coverage after your Initial Enrollment Period, you may have to pay the penalty. It is generally based on how long you went without creditable coverage, and it can continue for as long as you have Part D coverage.
Review Your Prescription Coverage Every Year
Even if your Part D coverage has worked well in the past, your plan’s premium, formulary, pharmacy network or cost-sharing can change from year to year.
Make a list of:
- Every prescription medication you take
- The dosage of each medication
- How frequently you take it
- The pharmacies you normally use
- Your current plan information
Then compare that list with the plan’s current coverage details.
Where Can You Get Help?
Medicare.gov provides official information about Medicare prescription drug coverage, including plan comparisons and enrollment information.
You can also contact your local State Health Insurance Assistance Program (SHIP) for free, personalized Medicare counseling. SHIP counselors aren’t connected to insurance companies or health plans.
Frequently Asked Questions
What is Medicare Part D?
Part D is Medicare’s prescription drug coverage, offered through private insurance companies approved by Medicare.
Is Part D included with Medicare Advantage?
Many Medicare Advantage plans include Part D prescription drug coverage. With Original Medicare, you can generally join a separate drug plan.
What is a formulary?
A formulary is a plan’s list of covered prescription drugs. Each Part D plan has its own formulary, so check that your medications are included.
What happens if I don’t enroll in Part D?
If you go 63 days or more without creditable prescription drug coverage after your Initial Enrollment Period, you may have to pay a late enrollment penalty when you enroll later. Exceptions can apply.
Where can I get free help with Part D?
Your local State Health Insurance Assistance Program (SHIP) offers free, personalized Medicare counseling, and SHIP counselors aren’t connected to insurance companies or health plans.
Need Official Answers?
Visit Medicare.gov or call 1-800-MEDICARE.
Looking for a doctor, specialist or medical clinic? Explore the Apple IPA provider directory to find health care resources in your area.
This article is for general informational purposes only. It is not medical, insurance, legal or financial advice. Medicare coverage, costs and plan rules can change. For current information about your specific Part D coverage, visit Medicare.gov or contact Medicare directly. To find providers, visit appleipa.org.
