Prescription Drug Coverage

Original Medicare, Parts A & B

Original Medicare does not provide coverage for most retail prescription drugs (those you don’t receive during inpatient care, or at an outpatient clinic.) Medicare does, however, generally cover specific types of medication, which could be fully covered if you include Medigap.
These include:

  • Drugs and vaccines provided in a physician’s office or hospital outpatient care facility, such as chemotherapy medications
  • Medications administered via durable medical equipment, such as nebulizers or internal or external pumps
  • Immunosuppressive medication, commonly given after an organ transplant
  • Some self-administered medications that treat oral cancer or related anti-nausea medications
  • Some medications that treat End-Stage Renal failure
  • Blood clotting factors
  • Supplies for treating Diabetes, such as lancets, test strips, and glucose monitors

To get coverage for other prescriptions, there are two options; through a Medicare Advantage Prescription Drug plan (MAPD) or through a stand-alone Medicare Prescription Drug plan (PDP.)

Note: Remember that while Medicare Part D coverage is an optional benefit, if you delay enrollment after you’re first eligible, you may have to pay a penalty to enroll later.

     Choosing a Plan

There are two important considerations when making your choice; monthly premium and the coverage of your specific prescriptions. Generally, the cost of prescription drugs is the more important one.

Every Prescription Drug Plan, whether it is stand-alone or bundled into a Medicare Advantage plan, has a list of the drugs they cover, called a “Formulary.” Each plan has its own formulary, so it is important to make sure that any plan you choose offers coverage for the prescription drugs you use. CMS does require that every plan offer at least two drugs in each therapeutic class. Also, that the plans all, or substantially all, drugs in six categories; antidepressants, antipsychotics, anticonvulsants, immunosuppressants, anti-cancer medications, and HIV/AIDS drugs. Part D drug plans also cover many common vaccines, including the shingles vaccine, to prevent illness.

Part D formularies are not required to offer some other categories, including; drugs used for cosmetic, rather than therapeutic reasons, such as hair growth; vitamins and minerals; fertility drugs; erectile dysfunction drugs; weight loss or gain drugs, cold and cough drugs, including syrups.
While the companies are not required to offer these,  occasionally one may choose to do so in any given year.

Since formularies change on a yearly basis, it’s important to check each year, to be sure your prescriptions are still covered. If that coverage is changing, it may be time to change plans.

When You Can Enroll

Whether you choose a stand-alone Part D drug plan or a Medicare Advantage plan, you must enroll during a designated enrollment period. Outside of these specified enrollment periods, you cannot enroll, no matter how urgently you require prescription medication. 

The enrollment periods are:

  • Your initial enrollment period (IEP), which runs for seven months, including the three before and three after the month of your 65th birthday.
  • The annual open enrollment period (Oct. 15 to Dec. 7 each year) when you can join a drug plan for the first time if you missed your deadlines for your IEP or a SEP, or switch from original Medicare to a Medicare Advantage plan, or switch from one Medicare Advantage plan to another, or switch from one Part D drug plan to another.
  • The annual “disenrollment” period (Jan. 1 to Feb. 14) when you can opt out of a Medicare Advantage plan (regardless of how long or short a time you’ve been enrolled) and return to the original Medicare program. During this period you can also join a stand-alone Part D drug plan, provided that you had been receiving drug coverage from the Medicare Advantage plan. 
  • A general enrollment period (Jan. 1 to March 31 each year), if you missed your deadline for signing up for Medicare (Part A and/or Part B) during your IEP or an SEP. In this situation Medicare coverage will not begin until July 1 of the same year in which you enroll. You can sign up for a Part D drug plan or a Medicare Advantage plan between April 1 and June 30 to begin receiving drug coverage under it on July 1. 
  • A special enrollment period (SEP), t0 which you may be entitled to in certain specific circumstances:

• If you qualify for Extra Help (which provides low-cost Part D coverage to people with limited incomes) or enter or leave a nursing home, you may join a Part D drug plan or switch to another at any time of the year.

• If you lose creditable drug coverage from another source; such as an employer, union, retiree benefits, COBRA, Medicaid, or the Veterans Affairs health care program; you can sign up with a drug plan within two months of this coverage ending. 

• If you move outside of your current drug plan’s service area (which means to another state if you’re enrolled in a stand-alone Part D plan), you can sign up with a new plan, either before or within two months of the move.

• If your current Part D plan withdraws service from your area, you can switch to another plan before or when your current coverage ends.

• If you return to the United States after living abroad, or are released from prison, you can sign up with a Part D drug plan within two months of your return or your release.

• If you want to switch to a Part D plan or a Medicare Advantage plan that has earned Medicare’s highest quality rating (five stars) and is available in your area, you can do so at any time of the year,  except for the first week of December .

• If a plan violates its contract with you, you can ask Medicare to investigate; if Medicare agrees, you can switch to another plan at that time. 

• If a federal employee made a mistake when processing your enrollment or disenrollment in a plan, you get a two-month SEP to switch to another plan if Medicare approves your claim. 

If you fail to sign up during one of these time frames, you face two consequences. You will be able to enroll in a Part D plan only during open enrollment, which runs from Oct. 15 to Dec. 7, with coverage beginning Jan. 1. Also, you will be liable for late penalties, based on how many months you were without Part D or alternative creditable coverage since turning 65, which will be added to your Part D drug premiums for all future years.

     Help with Costs

If you have limited income and resources, you may be able to get Extra Help paying your prescription drug coverage costs. People who qualify may be able to get their prescriptions filled and pay little or nothing out of pocket. If you have Medicare and Medicaid, you qualify for this Extra Help automatically and don’t need to apply.

If you are not enrolled in Medicaid, you can apply for Extra Help at any time, with no cost or obligation, so anyone who thinks they might qualify should apply.

You may apply through Social Security by visiting this page on their website, www.socialsecurity.gov/i1020, or calling 1-800-325-0778. You can also visit your State Medical Assistance (Medicaid) office. After you apply, you will get a letter in the mail letting you know what to do next.

Click here to download a PDF of this Guide.

I would be happy to help you check formularies and find the right plan for your needs.