Medicare Part D Explained: A Quick Guide for Financial Advisors

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The top two key areas that people without financial advisors say they want guidance on are retirement income planning and Social Security/Medicare advice. Additionally, one study found that the majority of clients (65%) expect health insurance advice from their advisor, but only 4% receive it. It's clear your clients want your guidance when it comes to Medicare, but in order to do that, you need to know the basic parts of Medicare. You don’t need to become an expert; having a solid understanding of the core components of Medicare will take you far. Last week I talked about Medigap plans, so this week I’m going to share everything you need to know about Medicare Part D. Let’s begin!

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What is Medicare Part D?

Original Medicare is made of four parts:

• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
• Medicare Part D (Drug Coverage)
• Medicare Supplemental (“Medigap”)

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Medicare Part D is specifically for drug coverage. If your client enrolls in Original Medicare, they’ll want to select a stand-alone prescription drug plan even if they don’t currently take any prescription medications. Why? If your client doesn’t enroll in Part D during their Initial Enrollment Period and goes more than 63 days without creditable drug coverage, they’ll be charged a Late Enrollment Penalty (LEP) fee. The Part D LEP fee will be applied indefinitely, regardless of whether your client changes plans. The LEP fee adds an extra 1% of the “national base beneficiary premium” for each month your client does not have creditable drug coverage for as long as they do have Part D coverage. If your client has creditable coverage and waived part D, they'll need to check every year that their plan still meets the guidelines for the upcoming year, as changes to Medicare part D might affect the client's plan's qualification.

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The national base beneficiary premium amount changes each year ($34.70 in 2024 and $36.78 in 2025), and the penalty fee will be rounded to the nearest $0.10 and added to your client’s monthly Part D premium. I’ve seen many clients not know this, and are unpleasantly surprised to learn that this penalty sticks with them for life.

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Are Part D plans offered through Medicare?

Although Medicare Parts A and B are offered by Medicare, Medicare Part D plans are provided by private insurance companies that contract with the federal government. If a beneficiary’s preferences align with Original Medicare over Medicare Advantage, it’s advisable to enroll in a private Medicare Part D plan to provide truly comprehensive coverage and avoid a Late Enrollment Penalty fee. Without a Medicare Part D plan, your clients will be paying entirely out-of-pocket for their medications.

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How much does Medicare Part D cost?

Each drug plan has its own formulary and separates drugs into different tiers, which affects overall drug costs. The pharmacy your client uses can also have an impact on their drug costs since not all pharmacies are considered in-network with all drug plans. Aside from actual drug costs, your client will also pay a monthly premium for their Part D drug plan. Again, the cost of this premium will depend on the individual plans. This year, there are some plans with a $0 monthly premium, however, it is advised that clients not automatically opt for those plans without checking the actual cost of their medications on those plans. 

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Additionally, your client’s income plays a part in how much they pay each month for Part D (and Part B) coverage. This income-related monthly adjustment amount (IRMAA) is based on your client’s tax filing status, the current year’s adjustment amount, and your client’s modified adjusted gross income from two years prior. For 2025, the standard base monthly premium for Part B is $185and increases based on the income band that your client falls within. For Part D, your client will pay their chosen plan’s premium plus their associated income adjustment. Below is a table of expected total costs:

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Until this year, the last component to consider was something called the “Medicare Donut Hole." This is when enrollees have to pay a higher percentage of their medication costs after spending a certain amount of money on their drugs. They keep paying this higher amount up to a certain limit before their plan begins paying again. That period where they have to pay the higher costs is where the Donut Hole got its name. But thanks to the Inflation Reduction Act, the Donut Hole is closed.

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The period where an enrollee must pay a higher proportion of their medication(s) has been reduced from what it used to be, and in 2025, Medicare enrollees won’t pay more than $2,000 in out-of-pocket costs for covered medications. But for coverage during 2024, the Medicare “Donut Hole” still applies. The only other time when an enrollee pays the full costs of their medications is when they're accruing costs toward their deductible—if their plan has one.

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Are there any medications that Medicare Part D doesn’t cover?

All Medicare drug plans, generally, must cover at least two drugs per drug category, but plans can choose which drugs covered by Part D they will offer. All Part D plans must cover all drugs available in the categories below:

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• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments for seizure disorders
• Immunosuppressant drugs
• Anticancer drugs (unless covered by Part B)

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Part D plans must also cover most vaccines, except for vaccines covered by Part B.

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Drugs not covered by Part D include:

• Over-the-counter drugs (even if they are prescribed by a physician).
• Drugs for weight loss or gain, even if used for non-cosmetic purposes, which is a hot topic currently with the rise of Ozempic.
• Cough and cold preparations, when prescribed for symptomatic relief only, without underlying medical indication.
• Fertility and erectile dysfunction drugs.
• Cosmetic and hair growth drugs.
• Drugs purchased in another country.
• Vitamins and minerals, except niacin products, Vitamin D analogs (when used for a medically accepted indication), prenatal vitamins, and fluoride preparations.
• Drugs that qualify to be covered under Part A or Part B, even if coverage is not actually available (e.g., because the individual has a Part A or B deductible, or does not yet have Part B.)

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Final Thoughts

If your client chooses to enroll in Original Medicare, they’ll need to also enroll in Medicare Part D and select a drug plan to ensure they have truly comprehensive health insurance and aren’t subject to a Late Enrollment Penalty fee. To help clients choose a Part D drug plan, a good starting place is to discuss their healthcare needs, the medications they take, and if they have any preferred pharmacies. Answering these questions will narrow down options for your client, and from there you can help them compare plan costs. Remember to look at the costs specifically for their medication list, not just the monthly premium. 

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We covered drug coverage for Original Medicare, but not Medicare Advantage. While that operates very similarly, that drug coverage is embedded within your chosen Medicare Advantage plan, which includes your medical coverage. More information about that and the information in this blog is available in Caribou’s Open Enrollment Resource Center and can help you confidently guide clients through the Medicare Open Enrollment process. But, if you really want to make healthcare planning a seamless experience for clients and yourself, schedule a call with me to learn how Caribou’s healthcare planning software supports financial goals and makes you the ultimate comprehensive financial planner.