From deductibles to donuts, key terms to know about Medicare Part D

From deductibles to donuts, key terms to know about Medicare Part D
Posted at 1:11 PM, Sep 21, 2018
and last updated 2018-11-07 22:53:40-05

(BPT) - Navigating the ins and outs of Medicare can be an intimidating experience if you’re not familiar with certain terms.

Medicare Part D, which helps cover prescription drugs, has its own terminology. Medicare Annual Enrollment runs from Oct. 15 to Dec. 7, so now is the time for a refresher on key words to inform your coverage decisions for 2019.

Deductible, copay and coinsurance

A deductible is the amount you pay out of pocket in a given year for eligible prescription drugs before your plan’s coverage kicks in. The deductible can vary from plan to plan.

Some plans charge a copay, a flat fee, each time you fill a prescription. For example, a plan may require you to pay $2 when you fill a prescription for generic drugs and a higher amount for brand-name drugs.

With coinsurance, you pay a set percentage of the cost of the drug instead of the flat fee associated with a copay.


Part D plans are offered by private insurance companies, and each plan has what’s known as a formulary, a list of the prescription drugs covered under the plan.

“When considering a Part D plan, review the formulary to make sure your medications are covered,” said Kent Monical, senior vice president for Part D at UnitedHealthcare Medicare & Retirement.

And keep in mind that plan formularies can change from year to year, so don’t assume that the prescription drugs covered under your current plan will carry over in 2019.

Drug tiers

A Medicare Part D plan’s formulary is made up of tiers, depending on the cost of the medications. The lower tiers generally include preferred generic drugs, and many plans cover these medicines with low or no copay or coinsurance.

Higher tiers generally include brand-name drugs and specialty medications and tend to have higher copays or coinsurance. So, talk to your doctor to see if the brand-name prescription you take can be replaced with a generic version.

Preferred pharmacy network

A Part D plan may designate a preferred network of pharmacies, and if you use these pharmacies, you can save money on prescriptions.

“Make sure the plan offers access to pharmacies that are convenient for you,” Monical said. “Some plans also have mail-order pharmacy benefits, and you may be able to get prescriptions delivered to your home for a lower cost than purchasing from a retail location.”

The donut hole

The majority of Part D plans have a coverage gap known as a “donut hole.” For example, in 2019, you enter this donut hole once your out-of-pocket costs (including deductibles, copays and coinsurance) for prescription drugs reach $3,820. While you’re in the donut hole, you will pay a percentage of the cost of the drugs.

In 2019, once your out-of-pocket costs reach $5,100, you exit the donut hole and pay a smaller coinsurance. But, the days of the donut hole are numbered. Under a provision of the 2010 Affordable Care Act, the coverage gap has been steadily shrinking. Beginning in 2019, the maximum you will pay in the coverage gap for a branded drug is 25 percent of a drug’s cost. For generic drugs, it is 37 percent, but in 2020, that will be reduced to 25 percent as well.

To learn more about Medicare or Medicare Annual Enrollment, visit