How Do You Switch
Depending on your circumstances, you can switch to a new Medicare drug plan simply by joining another drug plan during one of the times listed above. You dont need to cancel your old Medicare drug plan or send them anything. Your old Medicare drug plan coverage will end when your new drug plan begins. You should get a letter from your new Medicare drug plan telling you when your coverage begins.
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.
How Does A Tiered Formulary Work
Many plans have a tiered formulary where the plan’s list of drugs are divided into groups based on cost. In general, drugs in low tiers cost less than drugs in high tiers. Additionally, plans may charge a deductible for certain drug tiers and not for others, or the deductible amount may differ based on the tier.
Formulary tiers:
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The End Of The Political Deadlock
The congressional elections in November 2002 produced a political alignment not seen since the 1950s: Republicans were now in charge of the White House, the House of Representatives, and the Senate. In addition, two of the Republicans most interested in Medicare reformthe new Senate Majority Leader, Bill Frist , and the House Ways and Means Committee chair, Bill Thomaswere in a position to give the issue priority and exert considerable control over the legislative process. It became increasingly likely, therefore, that Congress and President Bush would agree to add outpatient prescription drug benefits to Medicare and that Republican leaders would make every effort to link those benefits to broader restructuring of the Medicare program .
In February 2003 President Bush made a major shift in strategy and decided not to propose detailed legislation but instead to offer only the general structure of a Medicare reform, incorporating prescription drug coverage in an effort to increase Medicare’s reliance on private health plans. In doing so, Bush followed the advice of his congressional liaisons and Republican legislators who said they wanted to draft their own reform plan .
What If I Don’t Agree With The Late Enrollment Penalty
You may be able to ask for a “reconsideration.” Your drug plan will send information about how to request a reconsideration.
Complete the form, and return it to the address or fax number listed on the form. You must do this within 60 days from the date on the letter telling you that you owe a late enrollment penalty. Also send any proof that supports your case, like a copy of your notice of creditable prescription drug coverage from an employer or union plan.
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What Parts Of Medicare Cover Pharmacy Home Delivery
Medicare Part A and Part B cover inpatient hospital care, home care, and outpatient services. While Medicare parts A and B will cover the cost of medications you receive from professionals at these facilities, the cost of your regular home medications is not covered by these parts of Medicare.
Medicare Part D is an optional part of Medicare that helps you pay for prescription medications.
Medicare Part D costs vary by plan and typically include:
- a monthly premium
- coverage gaps called the donut hole
- catastrophic coverage
To get help paying for your prescription medications, you must enroll in a Medicare Part D prescription drug plan, or in a Medicare Part CMedicare Advantageplan that offers Medicare Part A, Part B, and Part D prescription coverage all in one program.
While Medigap, a supplemental Medicare plan, offers coverage in addition to parts A and B, it does not cover prescription medications.
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Drugs That Are Not Covered By Medicare
While Part D covers prescriptions for a wide variety of medical conditions, not all drugs are covered. Some examples of prescription drugs that are not covered by Medicare Part D include:
- Brand-name drugs when a generic version is available
- Drugs used to treat anorexia, weight loss, or gain
- Over-the-counter medications
- Prescription vitamins and mineral products, except prenatal vitamins
- Drugs used for the treatment of sexual or erectile dysfunction
Its also important to know that the plans formulary might not include the specific drug prescribed to you. In this case, a similar drug should be available however, when this is not the case, you or your prescriber can request a formulary exception. If one or more of your prescriptions are not included in your plans formulary, you can change your plan during the open enrollment period, which is Oct. 15 to Dec. 7.
Note: Medicare supplement plans, like Medigaps, will not provide you with additional drug coverage. Medigaps only helps subsidize the cost-sharing associated with Original Medicare. These policies do not include any drug coverage at all.
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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What Is Not Covered By Medicare Part D Plans
The drugs you take may not be covered by every Part D plan. You need to review each plans drug list, or formulary, to see if your drugs are covered. The following will not be covered:
- Drugs not listed on a plan’s formulary
- Drugs prescribed for anorexia, weight loss or weight gain
- Drugs prescribed for fertility, erectile dysfunction, cosmetic purposes or hair growth
- Prescription vitamins and minerals
- Non-prescription drugs
- Drugs that are already covered by Medicare Part A and Part B
How Much Will It Cost
The amount youll pay for a Medicare prescription drug plan and your medications will depend on a number of factors, such as:
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The cost-sharing and premiums involved with your plan
-
How well your medications are covered
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The pharmacy you use
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Whether you reach the coverage gap or donut hole
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Whether you enroll in Medicares Extra Help program
Lets look at each of these in turn.
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Two Ways To Get Medicare Drug Coverage
Drug Plan with Original Medicare
If you choose Original Medicare, you can purchase a stand-alone Medicare Part D prescription drug plan through a private insurance company. For example, UnitedHealth Group, Humana, and CVS Health together insure about 56 percent of Medicare Part D enrollees. In 2021, half of Part D enrollees chose a stand-alone plan.3
Drug Plan with Medicare Advantage
If you enroll in a Medicare Advantage plan, most policies include prescription drug insurance. Half of Part D enrollees chose Medicare Advantage prescription drug plans .4 Aetna, Humana, and Blue Cross Blue Shield are some of the many insurance companies that offer Medicare Advantage plans with prescription drug coverage.
Eligibility For Part D
Anyone with Medicare is eligible to enroll in a Part D plan. To enroll in a PDP, the individual must have Part A OR Part B. To enroll in an MA-PD, the individual must have Part A AND Part B.
Enrollees must live in their plans service area. In the case of homeless persons, the following may be used as a permanent residence: a Post Office box, the address of a shelter or clinic, or the address where the person receives mail such as Social Security checks.
PDPs are usually national plans, but MA-PDs have delineated regions, sometimes by state, sometimes by counties within states ). For this reason, MA-PDs may not be appropriate for those who travel a great deal or who maintain summer and winter residences in different areas of the country. NOTE: Some MA-PDs offer passport plans that allow members to obtain benefits outside their normal service areas.
Individuals who reside outside the United States* are not eligible to enroll, but may do so upon their return to the country. Incarcerated individuals may not enroll in Part D, but they may enroll upon release from prison. Prior to 2021, people with end-stage-renal-disease could not enroll in an MA-PD. Starting in 2021, people with ESRD can enroll in Medicare Advantage plans during the annual Open Enrollment Period.
There are no other eligibility restrictions or requirements for Part D.
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Finding A Medicare Advantage Plan With Prescription Drug Coverage
A person can view available Medicare Advantage plans in their area by using Medicares Find a Medicare Plan function. This function allows a person to search by area for available plans that offer prescription drug coverage.
If desired, a person can enter the names, dosages, and quantity of medications they regularly take to see how plans cover these medicines.
A person can sign up for a Medicare Advantage plan that includes a prescription drug plan at the following times:
Initial Enrollment Period: This period starts 3 months before a persons 65th birthday, spans the month they reach 65 years, and finishes 3 months after their birth month.
A person can sign up for Medicare Advantage during this time.
Open Enrollment Period: This spans from . During this window, a person can sign up for a Medicare Advantage plan or switch from one to another.
Medicare Advantage Open Enrollment Period: This annual period runs from and has more limitations on enrollment compared to the fall.
During this time, a person can change from one Medicare Advantage plan to another or drop their Medicare Advantage plan and return to Original Medicare.
Special Enrollment Periods: A person may qualify in special circumstances, such as losing their employers health coverage or moving to an area to which the plans network does not extend.
What Is The Late Enrollment Penalty
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 www.medicare.gov.
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Medicare Part D: Medicare Prescription Drug Coverage
Medicare offers prescription drug coverage to everyone with Medicare. Medicare Part D plans are offered by private companies to help cover the cost of prescription drugs. Everyone with Medicare can get this optional coverage to help lower their prescription drug costs. Medicare Part D generally covers both brand-name and generic prescription drugs at participating pharmacies.
How To Get Prescription Drug Coverage With Medicare
There are different ways to get prescription drug coverage.
A person can purchase Part D plans individually, providing they already have Original Medicare, or parts A and B. Someone can also use prescription drug coverage, if they select it, alongside:
- select Private Fee-for-Service plans
- some Medical Savings Account plans
- Medicare Cost plans
Alternatively, a person can get Part D as part of a Medicare Advantage policy. Medicare Advantage typically bundles A, B, and D together in one plan. It is important to note that an individual must have Medicare parts A and B to be eligible for Medicare Advantage.
Some types of Medicare Advantage plans may not offer Part D coverage, so a person should compare plans before enrollment. In those cases, an individual may be able to add Part D coverage.
However, in this case, someone may be disenrolled from Medicare Advantage and returned to original Medicare coverage. Examples of plans that this policy could affect include:
- Health Maintenance Organization plans
- HMO Point-of-Service plans
- Preferred Provider Organization plans
A person who wishes to do this without losing their Medicare Advantage coverage can only do so in:
- private fee-for-service plans
- cost plans
- some employer-sponsored Medicare health plans
- registering online, either through the Medicare Plan Finder or the insurance providers website
- completing and mailing a paper enrollment form
A person can compare Part D plans using the Medicare Plan Finder.
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How To Pay For Part D
After youve signed up, youll pay monthly Part D premiums to the insurance company. You may either receive bills or sign up for automatic payments. You also may be able to request that your premium be deducted from your monthly Social Security or Railroad Retirement Board payment.
Medicare beneficiaries with low incomes and few assets may qualify for the federal Extra Help program that givesfinancial assistance to pay for Part D premiums, deductibles and copayments.
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Can I Enroll In Medicare Part D After My Initial Enrollment Period
In most cases, enrollment outside of your initial enrollment period is limited to an annual enrollment period between October 15 and December 7, with coverage starting January 1 of the following year. During this time, you can switch to a new PDP or Medicare Advantage plan, and coverage is guaranteed issue. The new plan will automatically replace the old one, so you dont need to do anything other than enroll in the new plan.
If you are enrolled in a Medicare Advantage plan and want to switch to Original Medicare, you can do so either during the fall open enrollment period or during the Medicare Advantage open enrollment period . If you do so, youll also have the option to purchase a Part D plan at the same time, so that youll have prescription coverage to go along with your Original Medicare coverage.
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The Medicare Prescription Drug Coverage Gap
Most Medicare Part D plans have a coverage gap, sometimes called the Doughnut Hole. This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for the drugs, up to a yearly limit. Your yearly deductible, coinsurance or copayments, and what you pay while in the coverage gap all count toward this out-of-pocket limit. The limit does not include the drug plans premium or what you pay for drugs that are not on your plans formulary or prescription drug list.
There are plans that offer some 250coverage during the gap, like for generic drugs. However, plans with gap coverage may charge a higher monthly premium. Check with the plan first to see if your drugs would be covered during the gap.
Once a person reaches the plans out-of-pocket limit during the coverage gap, catastrophic coverage automatically kicks in. Catastrophic coverage assures that once a person has spent up to the plans out-of-pocket limit for covered drugs, he or she will only pay a small coinsurance amount or a copayment for the rest of the year.
It is important to note that people who get Extra Help paying drug costs will not have a coverage gap and will pay a small or no copayment once they reach catastrophic coverage.
