Last Updated on
October 6, 2016
Prescription drug coverage is an option you can add to your Medicare benefits, and it’s available in Colorado (as in all states) through Medicare Part D. Original Medicare (Part A and Part B) doesn’t cover prescription drugs (except in limited situations, such as for an inpatient stay in a Medicare approved facility).
Under the Medicare Part D program, private insurance companies contract with Medicare to offer plans that help beneficiaries cover prescription drug costs. You may choose to enroll in a stand-alone Medicare Part D prescription drug plan to work alongside your Original Medicare, Part A and Part B, benefits. Or, you can sign up for a Medicare Advantage Prescription Drug plan, thus getting your health and drug benefits in a single plan.
Each Medicare plan that includes prescription drug coverage in Colorado may have different costs; plans may require that you pay a monthly premium, annual deductible, and/or copayment or coinsurance. Plan availability varies, depending on your zip code.
Before you sign up for a Medicare plan that includes prescription drug coverage, it’s important that you understand the basics of the Medicare Part D program: its drug formularies; how you qualify for it; and when you can enroll.
In Colorado, as in the rest of the United States, each Medicare plan that includes prescription drug coverage has its own list (or formulary) of covered prescription drugs. A formulary lists drugs in different categories (called tiers), each with a different cost. Generally, the most affordable drugs are placed in the lower tiers, while more expensive medications are listed in the highest tiers. If your doctor determines that a drug in a higher tier is necessary for your medical condition instead of a similar drug in a lower tier, you or your doctor can ask your plan for a tiering exception, to see if you can get lower cost-sharing for a higher tier drug. The formulary may change at any time. You will receive notice from your plan when necessary.
Medicare plans that include prescription drug coverage in Colorado, as in all states, generally let you choose between brand-name drugs and generic drugs. Generic drugs must have the same active ingredients as brand-name drugs, as well as be at the same strength and dosage and be proven to perform the same as brand-name drugs, according to the Food and Drug Administration. Generic drugs are usually more affordable than the brand-name versions. In some cases, the drug your doctor prescribed may be unavailable in your plan’s formulary or at your pharmacy. Talk to your doctor about whether another drug can be substituted.
You can qualify to sign up for a stand-alone Medicare Part D Prescription Drug Plan if you’re already enrolled, or are eligible to enroll, in Original Medicare, Part A or Part B. You must reside in the service area of your plan.
You may enroll in a stand-alone Medicare Part D Prescription Drug plan during the seven months starting three months before the month you qualify for Medicare, and continuing three months after that month. This time span is the Medicare Initial Enrollment Period.
If you choose to enroll in a Medicare Advantage Prescription Drug plan, you need to have both Medicare Part A and Part B to qualify, and you need to live within the plan’s service area. In most cases, you can sign up for a Medicare Advantage plan even if you have a pre-existing condition, except for end-stage renal disease (ESRD) for which enrollment limitations apply.
You may also enroll in Medicare Advantage or a stand-alone Medicare Part D Prescription Drug Plan during the Annual Election Period, which runs from October 15 to December 7, and you may switch plans during that same period. If you’re enrolled in a Medicare Advantage plan in Colorado and decide to switch back to Original Medicare, you can do so during the Medicare Advantage Disenrollment Period, which runs from January 1 to February 14 each year. You have until February 14 to add a stand-alone Medicare Part D Prescription Drug Plan if you want this coverage.
It’s important for you to know that if you don’t have creditable drug coverage for 63 days or more after your Initial Enrollment Period ends, you may be subject to a late-enrollment penalty for Medicare Part D if you ever decide to get this coverage. Medicare calculates this penalty using 1% of the national base beneficiary premium and the number of full months you were eligible for Medicare prescription drug coverage but didn’t sign up. This amount is then added to the monthly premium of your Medicare plan that includes prescription drug coverage. The national base beneficiary premium may increase each year, which means your late-enrollment penalty may also increase annually.
Once you’ve decided to enroll in a Medicare plan that includes prescription drug coverage, you’ll see that there are a couple of ways to get this coverage in Colorado. You can choose a stand-alone Medicare Part D Prescription Drug Plan, which can work alongside your Original Medicare coverage. You can add a stand-alone Medicare Part D plan whether or not you’re enrolled in a Medicare Supplement (or Medigap) plan.
Another option is to sign up for a Medicare Advantage Prescription Drug plan, which combines health and prescription drug coverage into one single plan. Medicare Advantage plans must include Original Medicare (Part A and Part B) benefits (other than hospice care, which is covered under Part A). Medicare Advantage plans sometimes carry additional benefits like routine vision, hearing, and dental, all for a single premium (or, in some cases, a $0 premium). Of course, you must also continue paying your Medicare Part B premium in this case as well.
It may also be a good idea to take into consideration your individual prescription needs when comparing Medicare plans in Colorado. Ultimately, it may be your prescription drug costs, rather than your premiums or deductibles that could determine your out-of-pocket expenses.
You may also want to review your Medicare prescription drug plan at the end of every year to find out if there are any changes to your coverage. Medicare plans that include prescription drug coverage in Colorado, as in the rest of the United States, can change their premiums, copayments, deductibles, and drug formularies annually. This means that your current prescription drug plan may not necessarily be the one that may meets your needs next year.
Please note that Medicare plan availability and costs vary by location. You can find plans available in your area by entering your zip code in the form on this page; the tool also lets you enter your prescription medications to narrow your search.
See any of the following for more information about Medicare plan options in Colorado: