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Medicare Prescription Drug Coverage (Part D)

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(Information included below courtesy of GeorgiaCares State Health Insurance Assistance Program. Daniel D. Munster, P.C. reprints this with permission and reminds the reader that it is included for informational purposes only and should not be considered legal advice)
Medicare offers prescription drug coverage (Part D) for everyone with Medicare. To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If you want Medicare drug coverage, you need to choose a plan that best meets your healthcare needs.

There are two ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare (Parts A and B) and some Medicare Advantage Plans (Part C).

2. Medicare Advantage Plans that offer prescription drug coverage. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” You get all of your Part A and Part B coverage, including prescription drug coverage (Part D), through these plans.

Even if you do not take a lot of prescription drugs, you should still consider joining a Medicare drug plan. If you do not sign up for Medicare Part D when you first become eligible or during a special enrollment period, you may pay a late enrollment penalty (1% penalty for each month you did not have creditable coverage after you were eligible to join a Medicare drug plan). If you have limited income and resources, you may qualify for extra help from Medicare and Medicaid to pay for your prescription drug coverage.

Who can get Medicare Drug Coverage?

To join a Medicare Prescription Drug Plan, you must have Medicare Part A and/or B. To join a Medicare Advantage Plan, you must have Parts A and B. You must also live in the service area of the Medicare drug plan you want to join.

Once you choose a Medicare drug plan, you may be able to join by completing a paper application, calling the plan, enrolling online or contacting GeorgiaCares (1-800-669-8387). Medicare drug plans are not allowed to call you to enroll you in a plan.

When can you join, switch or drop a Medicare Drug Plan?

You can join, switch or drop a Medicare drug plan at these times:

  • Initial Enrollment Period – When you first become eligible for Medicare. The 3 months before you turn age 65 to 3 months after the month you turn age 65.
  • General Enrollment Period – Between November 15 – December 31 each year. Coverage will begin January 1.
  • Special Enrollment Period – 1) If you move out of your plan’s service area; 2) if you have both Medicare and Medicaid; 3) if you qualify for low income subsidy (“extra help”); or 4) if you live in an institution (e.g., nursing home). Other situations may qualify you for a special enrollment period.

Often times, you can switch to a new Medicare drug plan simply by joining another drug plan. You do not 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 welcome packet from your new drug plan stating when your coverage begins.

How much does Medicare Drug Coverage cost?

Exact coverage and costs are different for each plan, but all Medicare drug plans must provide at least a standard level of coverage set by Medicare.

These are some payments you may make throughout the year in a Medicare drug plan:

  • Monthly premium
  • Yearly deductible
  • Copayments or coinsurance

You have choices in the way you pay your Medicare drug plan premium. Depending on your plan and your situation, you may be able to pay your Medicare drug plan premium in one of four ways: deducted from your checking or savings account; charged to a credit or debit card; billed to you each month directly by the plan; or deducted from your Social Security payment.

Considerations for Medicare Prescription Drug Plans

Plans may have the following coverage rules:

  • Prior authorization – You and/or your doctor must contact the plan before you can fill certain prescriptions.
  • Quantity limits – Limits how many pills you can get at a time.
  • Step therapy – You must try one or more similar, lower cost drugs before the plan will cover the drug your doctor prescribed.

If your doctor believes that one of these coverage rules should be waived, you can ask for an exception.

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