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Do I Have To Have Part D Medicare

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Medicare Part D: Key Takeaways

Do I Need Medicare Part D?
  • The only source of prescription drug plans is through private insurance companies.
  • Most Medicare Advantage plans include prescription drug coverage.
  • You can also purchase a stand-alone prescription drug plan if youre enrolled in a PFFS or MSA plan that doesnt include prescription coverage.
  • Your first opportunity to enroll in Part D is when youre initially eligible for Medicare.
  • You have the option of selecting an Advantage plan and using that in place of Medicare A, B, and D.
  • In most cases, enrollment outside of your initial enrollment period is limited to an annual enrollment period.
  • If you dont enroll in prescription drug coverage during your initial open enrollment and then enroll during a subsequent annual enrollment period, a late enrollment penalty will be added to your premium.

As of September 2021, more than 49 million Medicare beneficiaries had prescription drug coverage through Medicare Part D. The total is split nearly equally between those who have Part D coverage in conjunction with a Medicare Advantage plan , and those who have stand-alone Part D prescription drug plans , most of which are purchased to supplement Original Medicare.

But the balance has started to shift towards MAPD coverage, and it has recently surpassed the number of people with stand-alone PDP coverage .

Low Income Subsidy Questions

  • I have both Medicare and full Medicaid coverage. Do I need to apply for extra help to pay for Medicare prescription drug coverage?

    No. The “extra help” is a subsidy that people with Medicare and Medicaid automatically qualify for without having to complete an application.

  • If I am enrolled in a Medicare Savings Program, do I have to apply for “extra help”?

    If you do not have Medicaid, but Medicaid pays your Medicare Part B premium, you automatically qualify for “extra help” and you don’t need to apply.

  • If I do not qualify for NYS Medicaid or the Medicare Savings Program, can I still qualify for “extra help”?

    You may still be eligible for “extra help” to pay for the Medicare prescription drug plan premiums. To apply for extra help, you should visit or call your local Social Security Administration office or apply on line at

  • How To Check Your Medicare Application Online

    If you applied for Medicare online, you can check the status of your application through your Medicare or Social Security account. You can also visit the Check Enrollment page on and find information about your enrollment status by entering your:

    You can also check the status of your application by visiting or calling a Social Security office.

    You can ask your pharmacy to check the status of your Medicare Part D enrollment by sending a test claim.

    You can also call the Member Services department of your Medicare Part D plan.

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    How Does Medicare Part D Work

    Medicare Part D covers prescription drugs that you use at home. Chemotherapy drugs and other medications that are administered intravenously are covered by Medicare Part B.

    Your out-of-pocket costs depend on the formulary of a given plan and the specific tier a drug falls in. Welcome to the world of Medicare-speak! Heres the translation:

    • Formulary. This is a plans list of drugs and medications a Medicare Part D plan covers. The formulary includes generic and brand-name drugs.
    • Tier. Medicare Part D plans sort drugs in their formulary into different groups. These groups determine how much an enrollee pays out of their own pocket.

    A common tier structure you might encounter looks like this:

    You have to consider more than just the premium for your Part D coverage, says Omdahl. You need to look at what you will be paying for your specific prescriptions.

    A Medicare Part D plan with a $60 monthly premium that doesnt have a copay for the two drugs you refill each month, for example, would cost you less than a zero-premium plan that charges you a $40 copay for each of those two drugs.

    And just to keep you on your toes, a drug that is Tier 1 in one plan can be Tier 2 in another. Moreover, plans are within their rights to shift a drugs tier at any time. The somewhat good news: they have to give you advance warning of changes, and every year during the annual enrollment period you can shop for a new plan that works better with your meds.

    Example Of Medicare Part D

    Medicare Part D: Do I Have to Enroll in a Drug Plan?

    Daniel is a veteran considering whether to opt into Medicare Part D. As an older American, Daniel is already covered by Medicare for various medical expenses. However, some of his prescription medications are not covered by Medicare, causing him to look for additional coverage.

    In researching his options, Daniel examines several plans offered by private insurers under the Medicare Part D program. In doing so, he realizes that because of his prior military service, he is already entitled to prescription drug coverage through the Veterans Affairs program. When comparing this VA plan against the terms and conditions offered by private insurers under Medicare Part D, he concludes that his best option is to rely on his VA benefits.

    For this reason, Daniel decides not to opt into Medicare Part D. Because his VA plan is recognized by the government as a form of creditable prescription drug coverage, he will not be charged a penalty for failing to opt into Part D.

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    Do You Have To Sign Up For Medicare At Age 65

    • Are you required to sign up for Medicare when you turn 65? The answer is more than just a simple yes or no. Be sure to find out when you should sign up so that you dont face a late enrollment penalty or a lapse in coverage.

    When you turn 65, you may have the opportunity to enroll in Medicare. But is it mandatory to sign up?

    Technically, it is not mandatory to sign up for Medicare at 65 or at any age, for that matter. But its important to consider the situations in which you might decide not to enroll in Medicare at 65 so that you can make sure not to have any lapse in health insurance coverage or face a Medicate late enrollment penalty.

    How To Cancel Medicare Easy Pay

    If you need to change your Medicare Easy Pay bank account, address, or any other information, resubmit your Medicare Easy Pay form but select the change option.

    If you no longer want to use Medicare Easy Pay for any reason, resubmit your Medicare Easy Pay form but select the stop option. Complete all the boxes in the form so that Medicare can locate your information to make changes.

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    Can I Delay Enrollment In Part D Coverage

    If you didnt enroll in prescription drug coverage either through a PDP or a Medicare Advantage plan during your initial open enrollment window and then you enroll during an open enrollment period in a future year, theres a late enrollment penalty that will be added to your premium .

    The Part D late enrollment penalty would also apply if you drop your prescription coverage for more than 63 days and then re-enroll during the open enrollment period. Its important to maintain continuous drug coverage from the time youre first eligible, both to protect against significant prescription costs, and also to avoid higher premiums when you ultimately re-enroll.

    What Should I Know About A Plans Drug List

    What to Know About Medicare Part D When Still Working

    Medicare Part D and Medicare Advantage plans have a drug list that tells you what drugs are covered by a plan. Medicare sets standards for the types of drugs Part D plans must cover, but each plan chooses the specific brand name and generic drugs to include on its formulary. Here are some important things to know:

    • A planâs drug list can change from year to year.
    • Plans can choose to add or remove drugs from their drug list each year. The list can also change for other reasons. For example, if a drug is taken off the market. Your plan will let you know if thereâs a coverage change to a drug youâre taking.
    • Many Part D plans have a tiered formulary.

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    Medicaid Recipients And The $50000 Pip Option

    Under the new auto no-fault law, recipients of Medicaid can select a $50,000 PIP medical expense option. This option is only available if:

  • the named insured is enrolled in Medicaid and
  • their spouse and resident-relatives are also covered under Medicaid, are covered under a qualified health insurance plan, or have PIP coverage under a separate auto insurance policy.
  • Does Medicaid Cover Auto Accident Injuries Under the New Law?

    If you are considering opting for this level of PIP coverage, it is absolutely crucial you first understand which services are not available through Medicaid but may be needed in the event of an auto accident. Again, CPAN has created a remarkable brochure for consumers to compare coverages.

    Please visit .

    What Do Medicare Part D Plans Cover

    Medicare prescription drug plans cover the following:

    • Types of drugs most commonly prescribed for Medicare beneficiaries as determined by federal standards
    • Specific brand name drugs and generic drugs included in the plan’s formulary
    • Commercially available vaccines not covered by Part B

    It is important to note that while Medicare Part D plans are required to cover certain common types of drugs, the specific generic and brand-name drugs they include on their formulary varies by plan. You will need to review a plan’s formulary to see if the drugs you need are covered.

    Read Also: What Does Cigna Medicare Supplement Cover

    What The Part B Late Enrollment Penalty

    If you do not have creditable coverage after you first become eligible for Medicare Part B, you incur a penalty that you will pay when you eventually do enroll in Part B.

    The late enrollment penalty fee amount is a 10 percent increase in your Part B premium for each 12-month period you could have enrolled in Part B but did not.

    • For example, if you did not enroll in Part B when first eligible and delayed your enrollment for 14 months , your standard Part B premium amount including your late enrollment penalty would be $187.11 per month.
    • This total includes the standard Part B premium of $170.10 per month, plus your late enrollment penalty of $17.01 per month .

    If you qualify for a Medicare Special Enrollment Period, you may not be required to pay the late enrollment penalty.

    D Appeals And Grievances

    Working Past 65? Beware of this common Medicare myth  The ...

    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


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    Learn More About Medicare

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    The vaccine is one of the core COVID-related services that are covered in full by Original Medicare and Medicare Advantage plans.

    Under a provision in the CARES Act, if a vaccine becomes available for COVID-19, it will be covered by Medicare Part B with no cost sharing for beneficiaries. That means you will not have to pay anything toward your Part B deductible or pay any Part B coinsurance for the vaccine, as long as your health care provider accepts Medicare assignment.

    You also wont owe anything for Medicare-approved services related to obtaining the vaccine, such as a doctors visit. This applies to beneficiaries with both Original Medicare and Medicare Advantage plans.

    Can I Select An Insurance Plan For My Medicare And Medicaid Benefits

    If you are dual eligible, you are can enroll in a dual eligible special needs plan that covers both Medicare and Medicaid benefits. These plans may also pay for expenses that Medicare and Medicaid dont over individually, including over-the-counter items, hearing aids, and vision or dental care.

    Beneficiaries who are dual eligible can change between Original Medicare and Medicare Advantage or switch Part D plans at each quarter.

    Read more about the Medicaid benefits available to Medicare enrollees.

    Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals. In addition to advocacy work, Josh helped implement health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including at Sachs Policy Group, where he worked with insurer, hospital and technology clients.

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    There Are 2 Ways To Get Medicare Drug Coverage:

    1. Medicare drug plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Private FeeforService plans, and Medical Savings Account plans. You must have


    to join a separate Medicare drug plan.

    or other

    with drug coverage. You get all of your Part A, Part B, and drug coverage, through these plans. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

    To join a Medicare drug plan, Medicare Advantage Plan, or other Medicare health plan with drug coverage, you must be a United States citizen or lawfully present in the United States.

    Visit to get specific Medicare drug plan and Medicare Advantage Plan costs, and call the plans youre interested in to get more details. For help comparing plan costs, contact your State Health Insurance Assistance Program .

    What Is The Late Enrollment Penalty

    Do I have to get Medicare Part B if I’m still working? Deferring Medicare Part B

    The Late Enrollment Penalty is a fee that is meant to encourage enrollment in a prescription drug plan at the point of eligibility. If you are enrolled in a Medicare prescription drug plan, you may owe a Late Enrollment Penalty, if for any 63 days or more after the Initial Enrollment Period, you went without 1 of these:

    • A Medicare Part D Prescription Plan
    • A Medicare Advantage Plan
    • Another Medicare health plan that offers Medicare prescription drug coverage

    The Late Enrollment Penalty is added to your monthly Part D premium for as long as you have Part D coverage, even if you change your Medicare Part D plan. The Late Enrollment Penalty amount changes each year. You may also have this penalty if you have a Medicare Advantage plan that includes prescription drug coverage . You can avoid the late enrollment penalty by making sure you enroll when you are eligible and keeping your coverage.

    If you qualify for Extra Help due to a lack of income or resources, you can enroll late without a penalty. However, if you lose Extra Help, you may be charged a penalty if you have a break in coverage.

    Medicare, not the Cigna Part D Plan, will determine the penalty amount. You will receive a letter from the plan notifying you of any penalty. For further questions or concerns about the Late Enrollment Penalty, call Medicare at 1 MEDICARE or visit

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    D Spending And Financing

    Part D Spending

    The Congressional Budget Office estimates that spending on Part D benefits will total $111 billion in 2022, representing 15% of net Medicare outlays . Part D spending depends on several factors, including the total number of Part D enrollees, their health status and drug use, the number of high-cost enrollees , the number of enrollees receiving the Low-Income Subsidy, and plansâ ability to negotiate discounts with drug companies and preferred pricing arrangements with pharmacies, and manage use . Federal law currently prohibits the Secretary of Health and Human Services from interfering in drug price negotiations between Part D plan sponsors and drug manufacturers.

    Part D Financing

    Financing for Part D comes from general revenues , beneficiary premiums , and state contributions . The monthly premium paid by enrollees is set to cover 25.5% of the cost of standard drug coverage. Medicare subsidizes the remaining 74.5%, based on bids submitted by plans for their expected benefit payments. Higher-income Part D enrollees pay a larger share of standard Part D costs, ranging from 35% to 85%, depending on income.

    Payments to Plans

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