Medicare Part D plays a major role in helping patients afford their prescriptions—but for many, it can be confusing. As a pharmacist, you’re often the first point of contact when patients have questions about their coverage, costs, or changes in benefits.
This blog reviews the most common Medicare Part D questions patients ask and provides talking points to help you explain them in clear, patient-friendly language.
Patient’s Frequently Asked Medicare Part D Questions
Who is eligible for Medicare Part D?
To enroll in Medicare Part D, patients must first qualify for Medicare Part A or Part B. Typical eligibility includes:
- Adults 65 or older.
- People receiving Social Security Disability Insurance (SSDI) for 24 months.
- Individuals diagnosed with end-stage renal disease (ESRD) or ALS (Lou Gehrig’s disease) may qualify earlier.
Remind patients that being eligible for Medicare doesn’t automatically enroll them in Part D. If they have other creditable coverage—such as an employer or union plan—they can delay Part D enrollment without penalty.
What types of Part D plans are available?
There are two main types of Medicare Part D plans patients might ask about:
- Stand-alone Prescription Drug Plans (PDPs) – These cover only prescription drugs and require you to have Medicare Part  A or Part  B.
- Medicare Advantage plans with drug coverage (MA‑PDs) – These combine hospital (Part  A), medical (Part B), and prescription drug (Part D) coverage in a single plan.
Formularies, copays, and coverage rules can vary widely between plans. Encourage patients to schedule a consultation with you and bring in their medication list each Open Enrollment period so you can help them compare coverage.
Do I need Part D if I already have coverage?
If their existing plan meets Medicare’s standards for creditable coverage, they don’t need to enroll in Part D. This might include:
- Employer or union plans
- TRICARE / TRICARE for Life (TFL)
- Indian Health Service (IHS)
- Other federal programs (FEHB, CHAMPVA)
Warn patients that if they drop creditable coverage and go more than 63 days without drug coverage, they may face a late enrollment penalty.
How does Medicare Part D work?
Medicare Part D is offered through private insurance companies. Here’s a simplified breakdown to help patients understand:
- Deductible: Maximum $590 in 2025 (some plans have lower or zero deductibles).
- Initial Coverage Phase: You pay copays or coinsurance until your out-of-pocket costs reach the annual cap.
- Catastrophic Phase: Once you reach the $2,000 out-of-pocket cap (2025), your Part D plan covers 100% of covered drugs for the rest of the year. In 2026, this cap is projected to rise to ~$2,100.
- Premiums: Vary by plan.
- Late enrollment penalties: Calculated if you delay enrollment without creditable coverage.
Be sure to inform patients that Medicare now offers optional payment plans to spread out costs over the year, helping with budgeting on fixed incomes.
What happens if I don’t enroll?
If patients skip Part D without creditable coverage for 63+ consecutive days, they may pay a lifetime late enrollment penalty.
Penalty formula:
1% × (number of full, uncovered months) × (national base beneficiary premium)
What if my medication isn’t on my plan’s formulary?
If a drug isn’t listed, patients can:
- Request a formulary exception (for medical necessity).
- Pay out-of-pocket.
- Appeal the plan’s decision.
Switch plans during Open Enrollment if another plan covers your medication.
Remind patients to review their plan every year—drug lists and tiers often change, and switching plans can save them money.
Does Medicare Part D cover vaccines?
Yes, but coverage depends on the vaccine:
- Part D: Covers most retail vaccines, including shingles (Shingrix) and Tdap.
- Part B: Covers flu, pneumococcal, and hepatitis B (for high-risk patients) at no cost.
Let patients know that once they hit the Part D out-of-pocket cap, cost-sharing for Part D vaccines becomes $0.
Are any drugs excluded from Part D?
Yes. Common exclusions include:
- Weight loss or gain drugs (except when prescribed for diabetes).
- Fertility treatments or cosmetic medications.
- Over-the-counter (OTC) medications (unless specifically allowed in your plan).
- Certain hospital-administered drugs (covered under Part  A or B).
Additional medicare info
Prescription costs can add up quickly, but there are several ways Medicare beneficiaries can keep expenses under control. From financial assistance programs to smart plan comparisons, here are key strategies to share with patients to make the most of their Medicare Part D coverage:
 Extra Help (Low-income subsidy):
The Extra Help program—also known as the Low-Income Subsidy—can significantly reduce out-of-pocket costs for Medicare beneficiaries with limited income or resources. Eligible individuals may qualify for lower or no premiums, reduced deductibles, and minimal copays for prescriptions.
Local tools & resources:
Direct patients to the Medicare Plan Finder to compare plans based on their medications, pharmacy preferences, and costs. They can also reach out to your local State Health Insurance Assistance Program (SHIP) for free, personalized counseling.
Â
Want more info on preparing patients for Medicare Open Enrollment?Â
Check out our how-to guide with insights and printable Medicare resources you can share with your patients to make Open Enrollment easier for them (and you!).Â
