Medicare Part D Tips: How to Get the Most Out of Your Prescription Drug Coverage

When you signed up for Medicare Part D, you probably breathed a sigh of relief. Finally, help paying for your medications. But if you're like most people, you might not be getting everything your plan offers. The truth is, Medicare Part D comes with benefits many people never use — and pitfalls that can cost you thousands of dollars.

The system isn't designed to make things easy. Plans change their formularies every year. Pharmacies charge different prices for the same medication. And unless you know where to look, you might miss out on programs that could slash your drug costs.

This guide walks you through practical tips for getting the most from your Part D coverage, from free vaccines you might not know about to cost-saving programs that could put thousands back in your pocket.

Understanding Your Part D Coverage Basics

Before we get into the tips, let's make sure we're all on the same page about how Part D actually works.

Medicare Part D is optional prescription drug coverage offered through private insurance companies approved by Medicare. You can get it as a standalone plan if you have Original Medicare, or it might be included in your Medicare Advantage plan.

In 2025, Part D coverage happens in phases. You start with a deductible phase where you pay the full negotiated price for your covered drugs until you meet your plan's deductible (up to $590 in 2025). Then you enter the initial coverage phase, where you typically pay 25% coinsurance for your medications.

Here's the good news: once your out-of-pocket spending reaches $2,000 in 2025, you enter catastrophic coverage and pay nothing for covered drugs for the rest of the year. This is a big change from previous years and provides real protection against high drug costs.

Tip #1: Review Your Plan's Formulary Annually

Your plan's formulary is the list of drugs it covers. This isn't a static document. Insurance companies change their formularies every year, and the medications you rely on might move to a more expensive tier or be dropped entirely.

Every Part D plan must cover at least two drugs in the most commonly prescribed categories, and all plans must cover certain protected drug classes. These protected classes include:

• HIV/AIDS medications
• Cancer drugs
• Antidepressants
• Antipsychotics
• Anticonvulsants
• Immunosuppressants for organ transplants

But beyond these protections, plans have flexibility in what they cover and how much you'll pay.

During the Annual Enrollment Period (October 15 through December 7), take time to check next year's formulary. Look at each medication you take and note which tier it's in. Lower tiers mean lower costs. If your drug moved to a higher tier or was removed, it's time to either switch plans or talk to your doctor about alternatives.

You can search formularies using the Medicare Plan Finder tool. Enter your medications, dosages, and preferred pharmacies to see exactly what you'll pay with each plan.

Tip #2: Take Advantage of Free Vaccines

Here's something that might surprise you: since January 2023, Medicare Part D covers all vaccines recommended by the Advisory Committee on Immunization Practices at no cost to you. That means no deductible, no copay, no coinsurance.

This is a huge benefit that many people don't know about. Vaccines that Part D now covers for free include:

Shingles vaccine (Shingrix): The CDC recommends two doses for adults 50 and older. Shingrix is more than 90% effective at preventing shingles and long-term nerve pain. Without coverage, each dose can cost over $200.

RSV vaccine: In 2023, about 6.5 million Medicare Part D enrollees received the new RSV vaccine at no cost. If you're 60 or older, talk to your doctor about whether this vaccine makes sense for you.

Tdap (tetanus, diphtheria, and pertussis): This booster protects against whooping cough and tetanus. Adults should get a Tdap booster if they haven't had one in the past 10 years.

The key is making sure your provider bills your Part D plan correctly. Some vaccines (like flu, pneumonia, COVID-19, and hepatitis B for those at risk) are covered under Medicare Part B, not Part D. But for vaccines covered by Part D, ask your doctor's office to call your plan before administering the shot to confirm they can bill Part D directly. This prevents billing errors that could leave you with an unexpected charge.

Tip #3: Use Mail Order for 90-Day Supplies

Getting your maintenance medications through mail order can save you money and hassle. Most Part D plans offer lower copays for 90-day supplies obtained through their preferred mail-order pharmacy.

Here's how the savings work: instead of paying three separate copays for three 30-day refills, you pay just one copay for a 90-day supply. For medications you take every day — like blood pressure pills, diabetes drugs, or cholesterol medications — this adds up fast.

Beyond the cost savings, mail order offers convenience:

• Automatic refills: Your prescriptions arrive before you run out
• Home delivery: No trips to the pharmacy
• Better adherence: You're less likely to skip doses when you don't have to remember to refill

To set up mail order, contact your Part D plan. They'll tell you which pharmacy benefits manager (PBM) they use — companies like Express Scripts, CVS Caremark, or OptumRx. You can usually submit prescriptions online, by phone, or have your doctor send them directly.

One important note: mail order works best for maintenance medications you take regularly. For new prescriptions or short-term medications, stick with your local pharmacy so you can start treatment right away and make sure the medication works for you before ordering a 90-day supply.

Tip #4: Choose Preferred Pharmacies in Your Network

Not all pharmacies charge the same amount, even within your plan's network. Most Medicare Part D plans have networks of lower-cost pharmacies where you'll pay less for your medications.

These "preferred" pharmacies have negotiated better rates with your insurance plan, and those savings get passed on to you through lower copays. The difference can be significant. For example, you might pay a $10 copay at a preferred pharmacy versus $30 at a standard network pharmacy for the exact same medication.

Check your plan's pharmacy directory to find preferred pharmacies near you. Many major chains — CVS, Walgreens, Walmart — participate as preferred pharmacies in at least some plans. But the specific pharmacies that are "preferred" vary by plan.

When comparing pharmacies, consider:

• Copay differences: How much will you actually save?
• Convenience: Is the preferred pharmacy close to you?
• Services: Does the pharmacy offer services you value, like medication synchronization or personal consultations with pharmacists?

If your current pharmacy isn't preferred, it might be worth switching. But if the preferred option is far away or doesn't offer services you need, calculate whether the savings justify the inconvenience.

Tip #5: Apply for Extra Help If You Qualify

This is perhaps the most important tip on this list. The Social Security Administration estimates that Extra Help has an average annual value of $6,200. That's more than $500 per month in savings on your prescription drug costs.

Extra Help (also called the Low Income Subsidy) helps people with limited income and resources pay for Part D premiums, deductibles, and copays. In 2025, you may qualify if your annual income is less than $23,475 for individuals or $31,725 for married couples living together.

You must also meet resource limits. Your individual resources cannot exceed $17,600, or $35,130 for married couples. Resources include things like bank accounts, stocks, and bonds, but don't include your home, car, or personal belongings.

If you qualify for Extra Help, here's what you'll pay in 2025:

• Zero premium (if you choose a plan at or below the benchmark amount)
• Zero deductible
• Maximum copays: $4.90 for generic drugs and $12.15 for brand-name drugs
• Zero copays once you reach catastrophic coverage

You automatically qualify for Extra Help if you receive Medicaid, Supplemental Security Income (SSI), or are enrolled in a Medicare Savings Program. Otherwise, you need to apply. The easiest way is online through the Social Security Administration. You can also apply by phone at 1-800-772-1213 or visit your local Social Security office.

Tip #6: Ask for Generic Medications

Generic substitution rates were 91.4% for retail pharmacies versus 88.8% for mail order pharmacies, showing that most prescriptions can be filled with generics. Generic drugs contain the same active ingredients as brand-name drugs and work the same way, but they cost significantly less.

Part D plans place drugs into tiers, and generics typically sit in the lowest tiers with the smallest copays. Moving from a brand-name drug in Tier 3 or 4 to a generic in Tier 1 could save you $50 or more per prescription.

When your doctor writes a prescription, ask: "Is there a generic version of this medication?" If they say yes, request that the prescription specify the generic. If they say the brand name is necessary, ask why. Sometimes there are legitimate medical reasons — maybe you've tried the generic and had side effects, or the brand-name drug has a specific formulation you need. But often, the brand name offers no advantage.

Your pharmacist can also help. If your doctor prescribed a brand-name drug and a generic is available, ask the pharmacist to contact your doctor about substituting. Most doctors are happy to approve the switch.

Tip #7: Request Exceptions and File Appeals When Needed

What happens when your plan doesn't cover a medication your doctor prescribed? You have options.

If your medication isn't on your plan's formulary, you can request a formulary exception. This asks your plan to cover the non-formulary drug. You'll need your doctor to support your request, explaining why you need this specific medication and why formulary alternatives won't work.

Some covered drugs require prior authorization — meaning your plan wants to review the prescription before approving coverage. Your doctor's office submits this paperwork, but the process can take several days. If you need the medication urgently, ask about an expedited review.

If your plan denies coverage, you have the right to appeal. The appeals process has multiple levels:

1. Redetermination: Your plan reviews its decision
2. Reconsideration: An independent review entity looks at your case
3. Administrative Law Judge hearing: A judge hears your appeal
4. Medicare Appeals Council review: The council reviews the judge's decision
5. Federal court review: Final level of appeal

Most denials get resolved at the first or second level. The key is acting quickly — you typically have 60 days to file an appeal — and providing strong documentation from your doctor about why you need the medication.

Tip #8: Time Your Enrollments Strategically

Medicare's Annual Enrollment Period runs from October 15 to December 7, and this is your main window to switch Part D plans. Changes you make during this period take effect January 1.

Every year, review your current plan and compare it to other options. Your needs might have changed. Maybe you're taking new medications that aren't well covered by your current plan, or maybe another plan offers better coverage at the pharmacy you prefer.

If you have Extra Help or full Medicaid, you get additional flexibility. Starting in 2025, people with Medicaid or Extra Help can change their drug coverage once per month. This gives you much more freedom to switch if you find a better option.

One critical thing to avoid: the Part D late enrollment penalty. If you go 63 or more days in a row without Part D or other creditable prescription drug coverage, you'll owe a penalty of 1% of the national base beneficiary premium ($36.78 in 2025) times the number of months you went without coverage. This penalty gets added to your monthly premium permanently — for as long as you have Part D.

Tip #9: Use the Medicare Plan Finder Tool

The Medicare Plan Finder is your best resource for comparing Part D plans based on your specific situation. This free tool from Medicare lets you enter your medications and see exactly what you'll pay with each available plan.

Here's how to use it effectively:

Enter all your medications: Include the drug name, dosage, and how often you take it. Be thorough — missing even one medication can throw off your cost estimates.

Add your preferred pharmacies: The tool shows costs at different pharmacies. Include both the pharmacy you currently use and any preferred pharmacies you're considering.

Look at total annual costs: Don't just focus on the monthly premium. The tool calculates your total yearly cost including premiums, deductibles, and estimated copays. A plan with a low premium might have high copays that make it more expensive overall.

Check plan star ratings: Medicare gives Part D plans ratings from one to five stars based on customer service, customer experience, complaints, performance, drug safety, and pricing accuracy. Higher-rated plans generally provide better service.

Run this comparison every year during the Annual Enrollment Period, even if you're happy with your current plan. Plans change their formularies and prices, so last year's best option might not be this year's.

Tip #10: Consider Total Annual Costs, Not Just Premiums

It's tempting to choose the plan with the lowest monthly premium or even a $0 premium plan. But that premium is just one piece of your total cost.

Two plans that cover your medicines may have very different costs depending on the copayments they charge for your drugs. A plan with a $0 premium might place all your medications in higher tiers with expensive copays. Meanwhile, a plan with a $40 monthly premium might put your drugs in lower tiers, saving you hundreds at the pharmacy.

When evaluating plans, calculate:

• Annual premiums: Monthly premium × 12
• Annual deductible: What you'll pay before coverage kicks in
• Estimated copays: Based on your actual medications
• Total out-of-pocket costs: Add it all up

The Medicare Plan Finder does this math for you, but it's important to understand what you're looking at. The plan with the lowest total annual cost is usually your best bet — unless it lacks important features like a preferred pharmacy near you or good customer service ratings.

Remember, in 2025, once your out-of-pocket spending reaches $2,000, you pay nothing for covered drugs for the rest of the year. This catastrophic coverage cap protects you from unlimited drug costs.

Lesser-Known Part D Benefits You Should Know About

Beyond the basics, Part D offers several programs that can help with drug costs.

Medicare Prescription Payment Plan: Starting in 2025, this new payment option lets you spread your out-of-pocket drug costs across the calendar year in monthly installments. It doesn't save you money, but it can help manage your monthly budget by smoothing out large pharmacy bills.

State Pharmaceutical Assistance Programs (SPAP): Some states offer programs that help pay Part D premiums and cost-sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Check with your state health insurance assistance program to see if your state offers SPAP.

Pharmaceutical Assistance Programs (PAPs): Drug manufacturers often run programs to help people afford their medications. Each company has different eligibility requirements, but many offer free or reduced-cost drugs to people who qualify. Contact the manufacturer of your expensive medications to ask about patient assistance.

Limited Income Newly Eligible Transition (LI NET): If you qualify for Extra Help but aren't yet enrolled in a Part D plan, LI NET provides temporary drug coverage for up to two months. This prevents gaps in coverage while you choose and enroll in a plan.

Medication Therapy Management: Some Part D plans offer free medication therapy management services. A pharmacist reviews all your medications to check for interactions, duplicate therapies, or opportunities to save money. If your plan offers this, take advantage of it.

Common Part D Mistakes to Avoid

Even people who understand Part D can make costly mistakes. Here are the biggest ones to watch out for:

Not reviewing annually: Your plan changes every year, and so do your medication needs. What worked last year might cost you more this year.

Focusing only on premiums: A $0 premium plan that puts your drugs in expensive tiers will cost you more than a plan with a modest premium and low copays.

Missing Extra Help eligibility: Millions of people qualify for Extra Help but never apply. If your income is near the limits, apply anyway — the worst they can say is no.

Ignoring formulary changes mid-year: Plans can remove drugs from their formulary or add restrictions during the year. You'll get notice of these changes, and you have rights to request exceptions or switch plans.

Paying for free vaccines: Since 2023, all ACIP-recommended vaccines should be free under Part D. If you're charged for vaccines like shingles or Tdap, question the bill and make sure your provider billed Part D correctly.

Not appealing denials: If your plan denies coverage for a medication you need, don't give up. The appeals process exists for a reason, and many denials are overturned with proper documentation.

How a Solace Advocate Can Help

Navigating Part D can be overwhelming, especially when you're dealing with expensive medications or complicated health needs. This is exactly where a Solace advocate makes a difference.

Your Solace advocate starts by learning your complete medication list and health situation. We don't just look at what you're paying now — we look for opportunities you might be missing. Maybe you qualify for Extra Help but never applied. Maybe there's a pharmaceutical assistance program for your most expensive drug. Maybe a different Part D plan would save you thousands.

During Annual Enrollment, your advocate compares plans for you. We enter your medications into the Medicare Plan Finder, analyze the results, and explain which plans offer the best value. We consider factors beyond just cost — like whether your preferred pharmacy is in-network, whether the plan has good customer service ratings, and whether it covers all your medications on a reasonable tier.

If your medication isn't covered, we help you through the exception and appeals process. We work with your doctor to gather the documentation your plan needs, we submit the paperwork correctly and on time, and we follow up until you get an answer. If the first appeal is denied, we help you with the next level.

We also identify assistance programs you might not know about. Drug manufacturers, nonprofit organizations, and state programs all offer help with medication costs, but finding and applying for them takes time and knowledge. Your advocate handles this research and paperwork for you.

Perhaps most importantly, we make sure your providers bill correctly. Billing errors are common — especially with the new vaccine coverage — and they can leave you paying for things that should be free. We review your Explanation of Benefits statements, catch errors, and get them fixed.

Throughout the year, your advocate stays on top of formulary changes and new medications. If your plan changes its coverage or you start a new drug, we're already thinking about how that affects your costs and what adjustments might help.

Frequently Asked Questions About Medicare Part D

Can I switch Part D plans if my medications aren't covered?

Yes, but the timing matters. During the Annual Enrollment Period (October 15 through December 7), anyone can switch Part D plans for any reason. Changes take effect January 1. If you have Extra Help or full Medicaid, you can change plans once per month throughout the year. Outside of these periods, you generally can't switch unless you qualify for a Special Enrollment Period due to a life change like moving or losing other coverage. If you need a medication that's not covered, request a formulary exception or appeal rather than waiting until enrollment season.

What happens if my drug is removed from the formulary mid-year?

If your Part D plan removes a drug from its formulary or adds new restrictions (like prior authorization or quantity limits) during the year, the plan must give you at least 60 days notice. During this time, you have options. You can request a formulary exception to keep the drug covered, you can ask your doctor to prescribe a covered alternative, or in some cases, you may qualify for a Special Enrollment Period to switch to a different plan. If the formulary change creates a significant cost increase or access problem, you might be able to switch plans outside the normal enrollment period.

Do I need Part D if I rarely take medications?

Even if you don't take regular medications now, enrolling in Part D when you're first eligible is usually smart. The reason is the late enrollment penalty. If you skip Part D and then enroll later (without having other creditable prescription drug coverage), you'll pay a permanent penalty added to your monthly premium. The penalty is 1% of the national base beneficiary premium for each month you went without coverage. Many Part D plans have low or even $0 premiums, so getting coverage now protects you from penalties and gives you immediate access if you suddenly need medication.

How does the $2,000 out-of-pocket cap work in 2025?

In 2025, once your out-of-pocket spending on covered Part D drugs reaches $2,000, you enter catastrophic coverage and pay $0 for covered drugs for the rest of the calendar year. This out-of-pocket amount includes what you pay for drugs, plus certain amounts paid on your behalf by programs like Extra Help, State Pharmaceutical Assistance Programs, or manufacturer discounts. It doesn't include your monthly premium. Your plan tracks your spending automatically through your Explanation of Benefits. Once you hit $2,000, your copays drop to zero for covered medications through December 31.

Can I use Part D coverage at any pharmacy?

You must use pharmacies in your Part D plan's network to get coverage. Most plans have large networks that include major chains and many independent pharmacies, so finding an in-network option is usually easy. Some plans designate certain pharmacies as "preferred," where you pay lower copays. You can use non-preferred network pharmacies, but you'll pay more. If you travel or split time between two locations, check that your plan has network pharmacies in both places. For mail-order prescriptions, you must use your plan's designated mail-order pharmacy, which is typically run by the plan's pharmacy benefit manager.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

Related Reading

• Understanding Medicare's Preventive Service Coverage
• Appeals and Grievances in Medicare Advantage Plans
• Why Won't My Insurance Cover My Prescription, and What Can I Do?
• How to Apply for a Medication Discount Program or Patient Assistance
• Open Enrollment and Patient Advocates: What You Need to Know

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