Medicare Prescription Drug Plan (Part D)

How does Medicare Prescription Drug Coverage (Part D) work?

Medicare prescription drug coverage is an optional benefit. Medicare drug coverage is offered to everyone with Medicare. Even if you don’t use prescription drugs now, you should consider joining a Medicare drug plan. If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage or get Extra Help, you’ll likely pay a late enrollment penalty if you join a plan later. Generally, you’ll pay this penalty for as long as you have Medicare prescription drug coverage. To get Medicare prescription drug coverage, you must join a plan approved by Medicare that offers Medicare drug coverage. Each plan can vary in cost and specific drugs covered. 

There are two ways to get Medicare prescription drug coverage:

  • Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) plans, and Medicare Medical Savings Account (MSA) plans. You must have Part A and/or Part B to join a Medicare Prescription Drug Plan.
  •  Medicare Advantage Plans or other Medicare health plans that offer Medicare prescription drug coverage. You get all of your Part A, Part B, and prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.” Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

In either case, you must live in the service area of the Medicare drug plan you want to join.

If you have employer or union coverage

Call your benefits administrator before you make any changes, or sign up for any other coverage. Signing up for other coverage could cause you to lose your employer or union health and drug coverage for you and your dependents. If you lose your employer or union coverage, you may not be able to get it back.

When can I join, switch, or drop a Medicare drug plan?

  • When you first become eligible for Medicare, you can join during your Initial Enrollment Period.
  • If you get Part B for the first time during the General Enrollment Period, you can also join a Medicare drug plan from April 1 through June 30 and your coverage will start on July 1.
  • You can join, switch, or drop a Medicare drug plan between October 15 through December 7 each year and your changes will take effect on January 1 of the following year, as long as the plan gets your request before December 7.
  • If you're enrolled in a Medicare Advantage Plan, you can join, switch, or drop a plan during the Medicare Advantage Open Enrollment Period between January 1 through March 31 each year. 
  • If you qualify for a Special Enrollment Period.

Special Enrollment Periods

Special Enrollment Periods are times when you can join, switch, or drop your Medicare drug coverage if you meet certain requirements. Generally you must stay enrolled in your Medicare drug plan for the entire year, but you may be able to change your coverage mid-year if you qualify for a  special Enrollment Period when certain events happen in your life. Check with your plan for more information.

For enrollment assistance or additional information, call SHIIP toll-free 1-855-408-1212 Monday through Friday from 8am to 5pm.

 

PDPs Available in NC

Extra Help Materials

Part D Prescription Drug Plans - More Information

How do I switch plans?

How do I switch plans?

You can switch to a new Medicare drug plan simply by joining another drug plan during one of the times listed above. You don’t need to cancel your old Medicare drug plan. Your old Medicare drug plan coverage will end when your new drug plan coverage  begins. You should get a letter from your new Medicare drug plan telling you when your coverage with the new plan begins. You can switch plans by calling SHIIP toll-free at 1-855-408-1212 Monday through Friday from 8am to 5pm.  Or, you may call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
 

How do I drop a Medicare drug plan?

How do I drop a Medicare drug plan?

If you want to drop your Medicare drug plan and don't want to join a new plan, you can only do so during certain times.  You can disenroll by calling 1-800-633-4227.  TTY users can call 1-877-486-2048.  You can also send a letter to the plan to tell them you want to disenroll.  If you drop your plan and want to join another Medicare drug plan later, you have to wait for an enrollment period.  You may have to pay a late enrollment penalty if you don't have creditable prescription drug coverage.

When can I join, switch, or drop a Medicare drug plan?

  • When you first become eligible for Medicare, you can join during your Initial Enrollment Period.
  • If you get Part B for the first time during the General Enrollment Period, you can also join a Medicare drug plan from April 1 through June 30 and your coverage will start on July 1.
  • You can join, switch, or drop a Medicare drug plan between October 15 through December 7 each year and your changes will take effect on January 1 of the following year, as long as the plan gets your request before December 7.
  • If you're enrolled in a Medicare Advantage Plan, you can join, switch, or drop a plan during the Medicare Advantage Open Enrollment Period between January 1 through March 31 each year. 
  • If you qualify for a Special Enrollment Period.
Evidence of Coverage

Evidence of Coverage

Review the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC) your plan sends you each year. The EOC gives you details about what the plan covers, how much you pay, and more. The ANOC includes any changes in coverage, costs,  rovider networks, service area, and more that will be effective in January. If you don’t get these important documents in early fall, contact your plan.

How much do I pay?

How much do I pay?

Monthly Premium

Most drug plans charge a monthly fee that varies by plan. You pay this in addition to the Part B premium. If you’re in a Medicare Advantage Plan or a Medicare Cost Plan that includes Medicare prescription drug coverage, the monthly premium may include an amount for prescription drug  overage. Note: Contact your drug plan (not Social Security or the Railroad Retirement Board (RRB)) if you want your premium deducted from your monthly Social Security or RRB payment. If you want to stop premium deductions and get billed directly, contact your drug plan. If you have a higher income, you might pay more for your Part D coverage. If your income is above a certain limit ($85,000 if you file individually or $170,000 if you’re married and file jointly), you’ll pay an extra amount in addition to your plan premium (sometimes called “Part D-IRMAA”). You’ll also have to pay this extra amount if you’re in a Medicare Advantage Plan that includes drug coverage. This doesn’t affect everyone, so most people won’t have to pay a higher amount. If you have to pay a higher amount for Part D, you’ll also pay an extra amount for your Part B premium. See page  2. Usually, the extra amount will be deducted from your Social Security check. If you get benefits from the Railroad Retirement Board (RRB), the extra amount will be deducted from your RRB check. If you’re billed the amount by Medicare or the RRB, you must pay the extra amount to Medicare or the RRB and not your plan. If you don’t pay the extra amount, you could lose your Part D coverage. You may not be able to enroll in another plan right away, and you may have to pay a late enrollment penalty for as long as you have Part D. If you have to pay an extra amount and you disagree (for example, you have a life event that lowers your income), visit socialsecurity.gov or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

Yearly Deductible

This is the amount  you must pay before your drug plan begins to pay its share of your covered drugs.  Some drug plans don't have a deductible.

Copayments or Coinsurance

These are the amounts you pay for your covered prescriptions after the deductible (if the plan has one). You pay your share and your drug plan pays its share for covered drugs. If you pay coinsurance, these amounts may vary throughout the year due to changes in the drug’s total cost.

Catastrophic Coverage

Once you’ve met your plan’s out-of-pocket cost requirements for the year, you automatically get “catastrophic coverage.” With catastrophic coverage, you only pay a reduced coinsurance amount or copayment for covered drugs for the rest of the year.