2022 Medicare Part D Benefits

• by Christian Worstell
• November 23, 2021
• Reviewed by John Krahnert

Part D plans have different formularies (drug lists), tiers, coverage rules and networks, which will affect how you get your drugs covered.

Make sure you review a plan’s benefit details before enrolling, especially the formulary. The formulary tells you what drugs are covered by a specific plan.

The Part D "donut hole" coverage gap may affect how much you have to pay out-of-pocket to use your Medicare Part D benefits in 2022.

Or call 1-800-557-6059 1-800-557-6059 TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!​

You also can compare Part D plan benefits available where you live and enroll in a Medicare prescription drug plan online when you visit MyRxPlans.com.

Medicare Part D formulary (drug lists) and tiers

Your Part D plan’s formulary and tiers will determine if your prescription drugs are covered and how much you will pay out-of-pocket for those drugs.

A formulary is a drug list that shows which drugs are covered by a plan. You may face higher out-of-pocket costs if you need a medication that is not on your plan’s approved drug list.

Many Part D plan formularies also place prescription drugs into different tiers. Drugs in different tiers will have different costs. Prescription drugs in lower tiers usually have smaller copayments than drugs in higher tiers.

Plan formulary updates

A Part D plan formulary may change from year to year. Insurance providers may change plan benefits as long as the changes follow Medicare guidelines.

If you currently take a covered prescription medication, your Part D plan provider must notify you if any formulary changes will impact your coverage.

Coverage rules

Part D prescription drug plan coverage rules may affect how and when you receive your prescription drugs.

The rules may include:

• Quantity limits
• Prior authorization
• Step therapy

If you or your medical practitioner believes that one of your Part D plan’s coverage rules should be waived, you may request a plan exception. Medicare.gov provides more information about your Part D coverage protections.

Quantity limits

Quantity limits are caps on how much prescription medication you can get during a specific time period.

Prior authorization

If a drug requires prior authorization, your medical practitioner must contact your insurance plan and explain that the prescription is medically necessary.

Step therapy

Step therapy is a form of prior authorization. It requires you to try less expensive drugs that are effective for treating your medical condition before you can move up to a more expensive drug. Your plan may require you to try a generic form of medication before it covers a brand-name prescription.

You and your medical practitioner must prove that the generic medication did not work before the insurance company approves the use of a more expensive drug.

Network pharmacies

Part D plans may have contracts with pharmacies in an established plan network. 

If you visit in-network pharmacies, your prescription drug costs may be lower. If you fill a prescription at a non-network pharmacy, your plan may not cover your medication’s cost at all.

Your Part D plan’s network pharmacies may include retail pharmacies, preferred pharmacies, mail-order programs, and 30- or 90-day retail pharmacy programs.

Or call 1-800-557-6059 1-800-557-6059 TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!​

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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