What is Medicare Part D?
Medicare Part D is an optional benefit available to every Medicare beneficiary. It is the part of Medicare that covers most outpatient prescription drugs. It is offered through private insurance companies either as a stand-alone plan or as a part of your bundled Medicare Advantage plan.
Each plan has a list of covered prescription drugs called a formulary. If a drug you need is not on the formulary, you can request an exception or file an appeal.
Formularies contain drug categories or a group of drugs that treat the same things or have similar effects on the body. All Part D plans are required to include at least two drugs from most categories and cover all drugs in these categories:
- HIV/AIDS treatments
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressant drugs
- Anticancer drugs (unless covered by Part B)
Most vaccines are also covered unless they are covered already by Part B.
There are also some drugs excluded from Medicare coverage by law like weight loss or gain drugs and over-the-counter drugs.
How to get prescription drug coverage
To get drug coverage from Medicare, you must join either a standalone Part D plan or receive it through a Medicare Advantage plan:
- Medicare Part D — A standalone Part D plan adds prescription drug coverage to Original Medicare, Medicare Cost Plans, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
- Medicare Advantage Plan — Along with all of your Part A, Part B, and extra benefits you gain through an Advantage plan, you can sometimes receive Part D prescription drug coverage through this “all-in-one” Medicare plan.
Your initial enrollment period begins three months before the month you turn 65 and continues until three months after you turn 65. If you are becoming eligible for Medicare because of a qualifying disability, your IEP begins three months before your 25th month of receiving Social Security or Railroad Retirement Board benefits and ends three months after.
However, there is an annual enrollment period and special enrollment period you must also familiarize yourself with:
Annual Enrollment Period — Medicare’s AEP begins October 15 and ends December 7 every year. Any changes you make during this time will typically take effect January 1 the following year. During AEP you can:
- Switch Medicare Advantage Plans from one that does not offer drug coverage to one that does or vice versa
- Join a Part D Plan
- Change your Part D Plan
- Drop your prescription drug coverage
Special Enrollment Period — A Special Enrollment Period is triggered and allows you to make changes to a Part D plan if any of this applies to you:
- Returning to the US after living permanently outside of the US
- You have Medicare AND Medicaid or get Extra Help paying for your Part D plan but have never had a change
- Recently had a change in your Extra Help paying for your prescription drug coverage (gained, had a change in the level of, or lost Extra Help)
- Recently and involuntarily lost your creditable prescription drug coverage
- You recently gained, had a change in level of, or lost Medicaid
- Experiencing a change in an employer or union
- Belong to a Pharmacy Assistance Program provided by your state
- Moved outside the service area of your current plan or recently moved and this plan is a new option
- Your current plan is ending its contract with Medicare or vice versa
- You recently left a PACE program (Program of All-Inclusive Care for the Elderly)
- You’re moving into, live in currently, or recently moved out of a nursing home or long-term care facility
- You want to make a change during Medicare Advantage Open Enrollment Period
- You’ve been enrolled in a plan by Medicare or your state and you want to choose a different option
- A weather-related emergency or major disaster has affected you. Or one of the other statements here applies but you were unable to make your enrollment because of the disaster
- You were recently released from incarceration
- Recently obtained lawful presence status in the US
There may be other reasons not listed above that also provide you with enrollment opportunities.
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