Free tool

Part D, stage by stage

Two plans with the same premium can differ by thousands of dollars a year for the same person. What decides it is where your drugs sit on each formulary and which stage your spending ends in.

Three stagesFive tiersFive levers

Pharmacist wearing a turban working at a computer in a pharmacy store with shelves filled with medicine.

What your prescriptions cost

Where a year of prescriptions lands

Drag the slider to see which coverage stage a year like yours ends in.

Your expected drug spend this year

$450 your own out-of-pocket spend, across the year

$0Year starts
$590Deductible cap
$2,000Annual cap

Thresholds are set for each plan year and vary by plan.

You would finish the year in

Deductible

You pay: The full negotiated price of your drugs
The plan pays: Nothing yet
This stage ends: Once you have paid the plan's deductible, up to $590
In plain words: You pay the plan's discounted price yourself until the deductible is satisfied. Many plans set a $0 deductible, and many apply the deductible only to higher tiers, so someone taking only tier 1 generics may never touch this stage at all.
Watch out: A plan advertising no deductible can still be the expensive choice if your drugs sit on tier 3 or above. Read which tiers the deductible applies to, not just whether there is one.

Have us run your medication list

Deductible

You pay the plan's discounted price yourself until the deductible is satisfied. Many plans set a $0 deductible, and many apply the deductible only to higher tiers, so someone taking only tier 1 generics may never touch this stage at all.

You pay: The full negotiated price of your drugs
Ends when: Once you have paid the plan's deductible, up to $590

A plan advertising no deductible can still be the expensive choice if your drugs sit on tier 3 or above. Read which tiers the deductible applies to, not just whether there is one.

Initial coverage

This is where most people spend the whole year. Your share is a fixed copay on lower tiers and a percentage on higher ones, which is why a single specialty drug can move you through this stage in a couple of months while a shelf of generics never gets you near the end of it.

You pay: A copay or coinsurance set by your drug's tier
Ends when: Once your own out-of-pocket spending for the year reaches the annual cap, about $2,000

Preferred pharmacy pricing applies here and it is the most overlooked variable in Part D. The same drug on the same plan can cost noticeably less at a preferred pharmacy or by mail order.

Catastrophic coverage

Once your out-of-pocket spending on covered drugs reaches the annual cap, you pay nothing more for them until the year ends. For people on high-cost specialty medication this is the single most important number in the whole system.

You pay: $0 for covered Part D drugs for the rest of the calendar year
Ends when: 31 December. The whole cycle restarts on 1 January

Only spending on covered drugs counts toward the cap. Anything off-formulary, and anything bought outside the plan, does not move you toward it at all.

The five formulary tiers

Two plans with the same premium can differ by thousands of dollars a year for the same person, purely because of where each one places their drugs.

Tier	What sits here	What you pay	Worth knowing
Tier 1Preferred generic	Common generics: lisinopril, metformin, atorvastatin	A small flat copay, often $0 to $5 at a preferred pharmacy	Usually exempt from the deductible. This is where you want as much of your list as possible.
Tier 2Generic	Generics the plan has not designated as preferred	A modest flat copay	Ask your prescriber whether a tier 1 equivalent exists. It often does.
Tier 3Preferred brand	Brand-name drugs the plan has negotiated favourable pricing on	A larger flat copay, sometimes coinsurance	The deductible commonly starts applying here, which is where plan choice starts to bite.
Tier 4Non-preferred drug	Brands and some generics without a negotiated preference	Usually coinsurance, a percentage of the price	A tier exception request can sometimes move a drug down a tier with prescriber support.
Tier 5Specialty	High-cost drugs, frequently injectables and biologics	Coinsurance of roughly a quarter to a third of the price	Tier 5 is generally not eligible for a tier exception. This is the tier that drives people to the out-of-pocket cap.

Scroll the table sideways for the full row.

Five levers when a drug is not covered properly

Tier exception

A request to have a drug covered at a lower tier's cost share.

When: When the lower-tier alternatives are not clinically appropriate for you.

How: Your prescriber submits a supporting statement. Decided plan by plan, and specialty tier drugs are usually excluded from this route.

Formulary exception

A request to cover a drug that is not on the plan's formulary at all.

When: When no covered alternative works, or the alternatives have failed or caused harm.

How: Prescriber statement plus a coverage determination request. If denied, there is a defined appeals ladder above it.

Prior authorisation and step therapy

Plan conditions that must be met before a drug is covered, or a requirement to try a cheaper drug first.

When: Flagged on the formulary against specific drugs. Check before you enrol, not at the pharmacy counter.

How: Your prescriber submits the clinical justification. Build in time: this is why January refills go wrong.

Extra Help (Low Income Subsidy)

A federal subsidy that cuts Part D premiums, deductibles and copays substantially.

When: If your income and resources fall under the published limits. Many people who qualify never apply.

How: Apply through Social Security. It also removes the Part D late-enrolment penalty. We screen for it at every appointment.

Medicare Prescription Payment Plan

An option to spread your out-of-pocket drug costs across the calendar year in monthly instalments.

When: Useful when a large cost lands in January and the bill is hard to absorb in one month.

How: You opt in through your plan. It does not reduce what you pay overall; it changes when you pay it.

Why January feels different from December

Part D runs on a calendar year, so three things can change on 1 January at once. The deductible resets, which means a plan with a deductible starts charging you the full discounted price again. Formularies are refiled, so a drug that sat on tier 2 can appear on tier 3 or tier 4 with a different cost share. And new restrictions can be added, including prior authorisation, step therapy and quantity limits.

All three are announced in the Annual Notice of Change your plan sends each autumn. Reading it in October means you can still act, because the Annual Enrollment Period runs 15 October to 7 December. Reading it in January means looking at a problem you generally cannot fix until the following autumn.

This is the single highest-value review we do, and it takes about twenty minutes.

Office hours

Part D clinic: bring your medication list

Drop in with your prescription list and we run it against every standalone Part D plan available at your address. No appointment, no charge, no follow-up calls unless you ask for them.

When: Thursday 13 November, 9:00 am - 2:00 pm
Where: Harborlight office, 2210 Central Avenue, St. Petersburg
Cost: Free, drop-in, Drop-in, 20-minute slots
Language: English and Español

Save a seat

Questions about prescription cover

Almost always yes, unless you have other creditable drug coverage such as an active employer plan or VA benefits. Going 63 days or more without creditable coverage after eligibility triggers a permanent late-enrolment penalty that is recalculated every year.

Deductible first, where you pay the plan's discounted price until the deductible is met. Then initial coverage, where you pay a tier-based copay or coinsurance. Then catastrophic coverage, where you pay nothing more for covered drugs once your out-of-pocket spending hits the annual cap. Our Part D stages tool walks through where a year's spend lands.

You can request a formulary exception with a supporting statement from your prescriber, ask about a covered alternative, or change plans at the next Annual Enrollment Period. We file these requests for clients regularly and they succeed more often than people expect.

A federal subsidy, also called the Low Income Subsidy, that substantially reduces Part D premiums, deductibles and copays if your income and resources fall under the published limits. It also removes the late-enrolment penalty. Many people who qualify never apply. We screen for it at every appointment.

Three usual reasons: the deductible reset, the drug moved tier when the plan refiled its formulary, or a new prior authorisation requirement was added. All three are visible in the Annual Notice of Change your plan sends each autumn, which is why the October review matters.

Bring the list. We will do the rest.

Twenty minutes with someone who will ask for your doctor list before naming a plan. If the right answer is the plan you already have, that is what you will hear.

(727) 555-0241

Mon - Thu 8:30 am - 5:30 pm · Friday 8:30 am - 3:00 pm · TTY 711 · Se habla español

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No cost to you, ever. We are compensated by carriers, not by the people we advise.

Part D, stage by stage

Where a year of prescriptions lands

Deductible

Deductible

Initial coverage

Catastrophic coverage

The five formulary tiers

Five levers when a drug is not covered properly

Tier exception

Formulary exception

Prior authorisation and step therapy

Extra Help (Low Income Subsidy)

Medicare Prescription Payment Plan

Why January feels different from December

Part D clinic: bring your medication list

Questions about prescription cover

I take no medication. Do I still need Part D?+

How do the coverage stages work?+

My drug is not on the formulary. What now?+

What is Extra Help?+

Why did my drug cost jump in January?+

Bring the list. We will do the rest.