The author focuses on the realities of Medicare Part D prescription drug coverage by reviewing the history, politics, and cost of the program. Epidemiologic data related to Medicare recipients are presented, and the disparities created by the Part D plan are identified. Medicare Part D pitfalls that result in medication non-adherence are discussed, along with ways for advanced practice nurses to avoid these consequences. The role of the APN as patient advocate and educator is also described. The author discusses the financial, ethical, and legal impact of the Medicare Prescription Drug Improvement and Modernization Act, along with bills on the floor of Congress designed to amend and expand this act. Various stakeholders’ competing and conflicting priorities are examined from both economic and healthcare perspectives. Ways for APNs to optimize Medicare Part D are presented, and barriers and facilitators of this plan are identified, along with possible negotiation points for APNs to lobby to achieve a more affordable and appropriate Rx drug benefit for seniors in the United States.