Medicare Part D Deductibles
Most of the 10–15 Medicare Part D Plans available (determined by the county in which you live) have a deductible. For 2026, the highest deductible permitted is $615; it is set by the Centers for Medicare & Medicaid Services (CMS).
However, not all drugs are subject to the deductible. The assigned tier of a drug determines if the deductible must be met before you pay a copay or co-insurance amount.
This is why, during the first few months of a Part D plan, clients often come back to us wondering why their drugs are “so expensive” or even questioning whether they are on the right plan.
For the most part, it’s a timing issue — until the annual deductible is met in those first few months, it costs a lot.
That’s why we save an electronic copy of each client’s Medicare Plan Finder analysis. It’s a handy way to review prior decisions and understand how costs and timing work once the year begins and charges occur.
Prior Authorizations
The Medicare Plan Finder reveals which drugs require prior authorization before the plan will pay for them. For those drugs that do, we recommend our clients do the following, even before the new plan year begins:
- Identify the person in the prescribing physician’s office who handles submission of the necessary medical documentation to Part D plans. This substantiates the clinical need for the medication and can only come from the prescribing physician.
- Tell them your drug requires a prior authorization for the new plan year and share a copy of your new ID card.
- Ask them to proactively initiate the process. First, so that when you need to refill your prescription, the prior authorization approval is already on file. Second, if the request is denied, being proactive gives your physician time to respond with additional clinical information as needed.
Specialty Pharmacies
For medications requiring special handling, monitoring, or education and support — especially surrounding self-administration — Medicare requires these drugs to be processed and delivered from an entity separate from your local pharmacy — a “Specialty Pharmacy.”
The specialty pharmacy is specific to the insurance company sponsoring the Part D plan. It may be a separate arm of the insurance company, or the plan may subcontract with entities that provide these services.
The need for a specialty pharmacy can arise mid-year if a new medication is prescribed. Some recommendations:
- Use your Part D plan portal to do some research. Then call customer service for specific guidance on your plan’s provisions for specialty pharmacy relationships.
- Create a relationship with the specialty pharmacy by calling them for specific instructions; then create a new patient portal with them. In these cases, you will now have two separate patient portals — one for your Part D plan, one for the specialty pharmacy.
- As with prior authorizations, contact your physician’s office so they may proactively send your prescription to the specialty pharmacy.
- Be careful to use the specialty pharmacy designated by your specific plan. A mistake can result in extraordinarily high costs!
New Drug Prescriptions
Thanks to electronic prescribing systems, your physician will often send the prescription to a pharmacy before you even leave their office. In those instances, you may only discover the drug is not covered when you go to pick up your medication.
Here is a way to prevent that from occurring:
- Before you have the prescription sent to the pharmacy, research the formulary of your plan to identify if the drug is listed as covered. If it is, note the tier to which it is assigned.
- If it requires prior authorization and/or a specialty pharmacy, notify your physician practice to make sure the plan requirements are met.
- If the drug is not covered, research what the cost will be, call the plan, and work with your physician to identify appropriate possibilities that may be covered.
- If it is not covered, but it is the best drug for you clinically, work with your physician’s office to file for a formulary exception.
Summary
Medicare Part D works differently from most employer plans, especially when it comes to drug costs and coverage rules. Deductibles, prior authorizations, specialty pharmacies, and more, all affect what you pay and when you get your medication.
Being proactive and taking time to understand how your plan works will make the remainder of the year go much more smoothly!