How Do I Get Medicare Prescription Drug Coverage
There are two ways to get prescription drug coverage.
- You can enroll in a stand-alone Medicare Part D plan. This coverage will be in addition to Original Medicare and/or a Medicare Supplement plan.
- You can enroll in a Medicare Advantage plan that includes prescription drug coverage. This coverage will combine your medical and prescription drug coverage.
Tip: If you dont enroll in prescription drug coverage when you’re first eligible to enroll in Medicare, you may face penalties. Find out how to avoid penalties.
What Is The Medicare Part D Late
If youâve gone 63 consecutive days without creditable prescription drug coverage, either because you didnât enroll when you were first eligible or because you lost your creditable coverage and didnât get new coverage in time, then you may have to pay a late-enrollment penalty when you do enroll into Medicare Part D.
The Medicare Part D late-enrollment penalty is added to the premium of the Part D Prescription Drug Plan you enroll into. Your Medicare Prescription Drug Plan determines this penalty by first calculating the number of uncovered months you were eligible for Medicare Part D, but didnât enroll under Part D or have creditable coverage. Your Medicare Prescription Drug Plan will then ask you if you had creditable prescription drug coverage during this time. If you didnât have creditable prescription drug coverage for 63 or more days in a row after you were first eligible, the Medicare Prescription Drug Plan must report the number of uncovered months to Medicare.
For example, letâs say you disenrolled from your Medicare Prescription Drug Plan effective February 28, 2021, and then decided to enroll into another Medicare Prescription Drug Plan during the Annual Election Period, with an effective date of January 1, 2022. This means you didnât have creditable prescription drug coverage from March 2021 through December 2021, which adds up to 10 uncovered months.
When Can You Enroll In Medicare Part D
To enroll into a Medicare Part D Prescription Drug Plan, you need to have either Medicare Part A or Part B, and you have to live in the service area of the plan you choose. If youâre eligible for Medicare because of age, your seven-month Initial Enrollment Period for Part D usually takes place at the same time as your Initial Enrollment Period for Part B, starting three months before your 65th birthday, including your birthday month, and ending three months later. If you qualify for Medicare through disability, youâll get a subsequent Initial Enrollment Period for Part D when you turn 65 years of age.
The Medicare Part D late-enrollment penalty may apply if you enroll any time after your Initial Enrollment Period for Part D and go without creditable prescription drug coverage for more than 63 days in a row. If you donât enroll in Medicare Part D when youâre first eligible, your next opportunity will be during the Annual Election Period that occurs from October 15 to December 7 of every year. During this time, you can enroll into a stand-alone Medicare Prescription Drug Plan if you have Original Medicare or get prescription drug coverage through a Medicare Advantage Prescription Drug plan. You can also use this period to switch plans or disenroll from your plan.
During the Medicare Advantage Open Enrollment Period , you may be able to make certain coverage changes. The OEP runs from January 1-March 31 each year.
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Do I Need Prescription Drug Coverage
Medicare Part D prescription drug coverage has been available as an option for Medicare enrollees since 2006. Before that, Medicare beneficiaries had to pay full cost for all their drugs, which was a financial burden for millions of people. Luckily, Medicare recipients have the opportunity to sign up for prescription drug coverage to help them with the high costs of medications.
Today in the United States, 45 million people, or 70 percent of all Medicare beneficiaries, are enrolled in a Prescription Drug Plan. According to the national average for 2020, the monthly base beneficiary premium for a Medicare prescription drug plan is $32.74. For most people who are enrolled, this cost is just a fraction of what they might spend on prescription drugs without this coverage.
If you are close to the age of eligibility for Medicare, you may be wondering if you should also sign up for prescription drug coverage. Even if you are not taking medications currently, there is no guarantee that this will be the case in the years to come. But making a decision to enroll in a Prescription Drug Plan is more complex than just basing it on what medications you take now, and it is worth taking the time to consider your options.
Here is some important information about prescription drug coverage, what it includes, and when you should enroll so you can avoid penalties.
You must either be a United States citizen or have been a legal resident of the U.S. for at least five years.
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Do I Need Medicare Part D Drug Coverage If I Dont Take Any Prescriptions
En español | If you dont have other drug coverage thats considered creditable, meaning at least as good as Part D, the answer is yes.
Unless you have creditable coverage from another source such as prescription coverage from an employer, former employer, Tricare, the Department of Veterans Affairs or another source you may have to pay a late enrollment penalty if you decide to sign up for Part D later.
Medicare calculates the penalty as 1 percent of the national average Part D premium for every month you delayed, and it can add up quickly. The monthly penalty lasts for as long as you have Part D coverage and increases every year the national average premium goes up.
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Can I Decline Medicare Altogether
Medicare isnt exactly mandatory, but it can be complicated to decline. Late enrollment comes with penalties, and some parts of the program are optional to add, like Medicare parts C and D. Medicare parts A and B are the foundation of Medicare, though, and to decline these comes with consequences.
The Social Security Administration oversees the Medicare program and recommends signing up for Medicare when you are initially eligible, even if you dont plan to retire or use your benefits right away. The exception is when you are still participating in an employer-based health plan, in which case you can sign up for Medicare late, usually without penalty.
While you can decline Medicare altogether, Part A at the very least is premium-free for most people, and wont cost you anything if you elect not to use it. Declining your Medicare Part A and Part B benefits completely is possible, but you are required to withdraw from all of your monthly benefits to do so. This means you can no longer receive Social Security or RRB benefits and must repay anything you have already received when you withdraw from the program.
Do You Have To Sign Up For Medicare At 65 If You Are Still Working
Countless elderly people depend on Medicare for health coverage upon retirement. But knowing when to register can help you get the most out of your benefits while avoiding unnecessary penalties.
Your Medicare coverage begins at exactly age 65, but you do not need to wait until your 65th birthday to register. Instead, your initial registration window begins three months before the month you turn 65 and ends three months after the month you turn 65. So, that said, you get a steady seven months to sign up.
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D Appeals And Grievances
Coverage Determinations and Exceptions
All Part D plans must have an appeal process through which members can challenge a denial of drug coverage. The Part D appeals process is based on and similar to the Part C appeals process.
Denials of drug coverage by a PDP or MA-PD are called coverage determinations. For example, a coverage determination may be issued by the plan if the drug is not considered medically necessary or if the drug was obtained from a non-network pharmacy. It is necessary to have a coverage determination in order to initiate an appeal. A doctors supporting statement is not required for this type of appeal, but it may be helpful to submit one. If the request for coverage is denied, the member may proceed to further levels of appeal, including redetermination by the plan, reconsideration by an Independent Review Entity , Administrative Law Judge review, the Medicare Appeals Council , or federal district court.
One type of coverage determination is called an exception request. An exception request is a coverage determination that requires a medical statement of support in order to proceed to appeal. There are two types of exceptions that may be requested:
Formulary Exceptions This type of exception is requested because the member:
- needs a drug that is not on the plans formulary,
- requests to have a utilization management requirement waived for a formulary drug).
What to do When a Drug is Denied at the Pharmacy
The Medical Statement
Grievances
When Should You Apply For Medicare
In most cases, you should apply for Medicare as soon as youre eligible. The initial enrollment period starts three months before the month you turn 65, includes your birth month, and extends three months past the month you turn 65, giving you a seven-month window to apply. Your Part B coverage will likely be delayed if you enroll the month you turn 65 , so apply early to avoid a gap in coverage.
Medicare imposes a hefty late enrollment penalty if you enroll in Part B or D after the initial enrollment period and dont qualify for a special enrollment period .You might qualify for a SEP if you have coverage, including creditable drug coverage from an employer or a union . Medicare does not charge a late enrollment penalty for enrolling in a Medicare Advantage plan or Medicare Supplement plan after IEP. But its best to apply for Medigap as soon as youre eligibleif you apply within the first six months of having Part B coverage, you cant be denied a Medigap policy or be required to pay more because of health conditions. Heres how enrollment works depending on whether or not you already receive Social Security benefits.
If you already receive Social Security benefits:
You should also check out the Medicare Enrollment Booklet which contains clear, concise information about both Medicare Part A and Part B.
If you are not yet receiving Social Security benefits:
When to get prescription drug coverage:
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I Am Covered By Medicare But I Dont Take Any Medications Do I Need To Sign Up For A Drug Plan
Even if you arent taking any medications right now, it might make sense to enroll in a drug plan so that you have coverage in case your needs change in the future. If you dont have coverage and the Medicare Open Enrollment period has ended, you wont be able to sign up for coverage until the next Medicare Open Enrollment period begins, and your coverage wouldnt take effect until January 1 of the following year. This could put you at risk of paying a lot out of pocket for prescriptions if your needs change. Also be aware that there is a late enrollment penalty for Part D. If you dont sign up for a Part D plan when you are first eligible to do so, and you decide later you want to sign up, you will be required to pay a late enrollment penalty equal to 1% of the national average premium amount for every month you didnt have coverage as good as the standard Part D benefit.
Who Is Eligible For Medicare Advantage Plans A B C And D
If you are currently receiving Social Security benefits and are under the age of 65, you will automatically be enrolled in Medicare Parts A and B when you turn 65. If you do not want to receive Medicare Part B, you can delay it at that time.
If you do not currently have Social Security, you will need to actively enroll in Medicare.
Once you know the dos and donts while signing up, the actual process becomes easy. The following factors are important to consider when enrolling in Medicare.
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What Costs Are Involved In A Part D Prescription Drug Plan
Costs you pay out-of-pocket for a Part D prescription drug plan include the following:
- Part D monthly premium: This is a flat fee you may have to pay to your plan for providing you with coverage.1
- Part B premium: You must continue to pay Part B premiums as part of your Original Medicare coverage.
- Copays and coinsurance: You and Medicare share a percentage of the costs for your prescription drugs. This means you pay part of your pharmacy drug costs and Medicare also pays part of your pharmacy drug costs.
If you choose a Medicare Advantage Plan that includes drug coverage, your monthly plan premium will include the medical and drug portion of the plan.
Note: In some cases, your premium may be higher if you didnt sign up for Part D when you first became eligible.
There are no cost breaks for married couples. Medicare requires each spouse to pay separate premiums, deductibles, copays, and coinsurance for prescription drug coverage. Each spouse will reach each level of coverage according to their own drug costs over each calendar year.
How To Join A Drug Plan
Once you choose a Medicare drug plan, here’s how to get prescription drug coverage:
- Enroll on the Medicare Plan Finderor on the plan’s website.
- Complete a paper enrollment form.
When you join a Medicare drug plan, you’ll give your Medicare Number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.
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When Do I Have To Apply For Medicare If Im Still Working
You dont have to apply for Medicare if youre working and have group medical coverage, but you may want to.
If you are an eligible, employed Medicare beneficiary who has group medical coverage, you may choose to delay Medicare enrollment. But Medicare could offer a cost savings and if your employer has less than 20 employees, youll have no choice but to enroll. Consider these important timelines and regulations when you apply for Medicare while still employed.
What Happens If My Prescription Drug Isnt Covered
Medicare mandates that there be at least two drugs from every therapeutic class in a formulary. But in some instances, you may need a drug that just doesnt make the list. If that happens, your doctor can contact the insurance company to request whats called a formulary exception. Your plan will review the request to see if they’ll cover it. Typically, if the drug is approved, it will be provided to you at the cost found in one of the top tiers, such as tier 4 or 5, which means you will usually be responsible for a higher percentage of the cost than if the medicine was in a lower tier.
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What Drugs Are Covered By Medicare Part D
Part D plans help pay for medications you take regularly to manage chronic conditions, for example, heart disease, high cholesterol, or asthma. It also pays for medications you take for a short period of time, such as antibiotics. There are also some medications covered by your Original Medicare Part B plan and not covered by Part D.
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Recent Articles And Updates
For older articles, please see our article archive.
References
The 2010 Medicare Part D $250 Donut Hole Rebate. Q1Group LLC, .
2020 Part D Income-Related Monthly Premium Adjustment. . .
2021 Medicare Part D Outlook. Q1Group LLC, .
2021 Part D Income-Related Monthly Premium Adjustment. . .
How Do Medicare Advantage Ppo Plans Work? Healthline Media, May 5, 2021, .
Analysis of Part D Beneficiary Access to Preferred Cost Sharing Pharmacies . . .
Announcement of Calendar Year 2021 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies. . .
Assistance with Paying for Prescription Drugs. Center for Medicare Advocacy, November 30, 2015, .
How Medicare Part D Works. AARP, October 2016, .
Medicare Advantage Special Needs Plans . Healthline Media, May 3, 2021, .
Kirchhoff, Suzanne M. Medicare Coverage of End-Stage Renal Disease . . .
Generally, youre first eligible to sign up for Part A and Part B starting 3 months before you turn 65 and ending 3 months after the month you turn 65.
Because the company has less than 20 employees, your job-based coverage might not pay for health services if you dont have both Part A and Part B.
