Last Updated on
October 6, 2016
The Medicare Part D program makes prescription drug benefits available to Medicare beneficiaries throughout the United States. Original Medicare, Part A (hospital insurance) and Part B (medical insurance), doesn’t include prescription drug coverage, except during a hospital stay. As a Medicare beneficiary living in Maine, you may receive Medicare prescription drug coverage from a stand-alone Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan. Costs and availability may vary, depending on the insurance company, the benefit coverage offered, and where you live in Maine. Most plans require you to pay a monthly premium, annual deductible, and copayment or coinsurance.
Two types of Medicare plans offering prescription drug coverage may be available where you reside in Maine. Both types of plans are offered by private insurance companies contracted with Medicare to provide prescription drug coverage to Medicare beneficiaries.
Stand-alone Medicare Part D Prescription Drug Plans are designed to work alongside Original Medicare coverage or coverage provided by a Medicare Advantage plan that does not include prescription drug coverage.
Alternatively, you can get your Medicare Part A (hospital insurance), Part B (medical insurance), and Part D (prescription drug insurance) coverage by enrolling in a Medicare Advantage Prescription Drug plan.
In Maine, as in the rest of the United States, each stand-alone Medicare Part D Prescription Drug Plan and Medicare Advantage Prescription Drug plan has its own list of covered prescription drugs, called a formulary. The formulary may change at any time. You will receive notice from your plan when necessary. The medications in the formulary may be grouped into different benefit categories called tiers, each with a different out-of-pocket cost you pay. The lower tiers include the less expensive prescriptions drugs, while the higher tiers include more expensive medications. If your doctor or other prescribing health provider decides that a drug in a higher tier is medically necessary for your health condition instead of a similar drug in a lower tier, you or your prescriber may ask your plan for a tiering exception to lower your cost for the higher-tier medication.
In general, stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans let you choose between brand-name drugs and generic equivalent drugs. Medicare.gov describes generic drugs as prescription drugs that have the same active-ingredient formula as brand-name drugs. Generic drugs usually cost less than the brand-name versions, which may result in lower out-of-pocket expenses. If your generic prescription drug is not available, the plan may sometimes let you substitute a similar generic drug rather than a brand-name medication. You should always discuss medication options and instructions with your doctor.
To enroll in a stand-alone Medicare Part D Prescription Drug Plan in Maine, as in any other state, you must be enrolled in Original Medicare, Part A and/or Part B. However, if you decide to get your Medicare prescription drug coverage through a Medicare Advantage Prescription Drug plan, you must have both Medicare Part A and Part B. Whether you choose a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, you must live in the plan’s service area.
There are certain designated times when you can enroll in a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan. Listed below are important dates to remember.
You can enroll in a stand-alone Medicare Part D Prescription Drug Plan during your Initial Enrollment Period. This lasts from the three months before the month you turn 65, your birthday month, and the three months after your birthday month. Alternatively, if you’re enrolled in Medicare due to a disability, your Initial Enrollment Period starts three months before your 25th month of disability, includes that month, and continues for three months after the 25th month of disability (seven consecutive months) .
Medicare Advantage Prescription Drug plans have an enrollment period called the Initial Coverage Election Period. It’s usually the same time period as the Initial Enrollment Period described above, unless you delay enrollment in Medicare Part B.
If you don’t sign up for prescription drug coverage when you’re first eligible, you can enroll in a stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan during the Annual Election Period. This period runs from October 15 to December 7 each year. You may change plans and make other coverage changes during this time. However, if you don’t sign up for drug coverage when you’re first eligible, you might have to pay a late-enrollment penalty if you do sign up later.
If you’re enrolled in a Medicare Advantage Prescription Drug plan and decide to switch back to Original Medicare, you may do so during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. During this period, you may add a stand-alone Medicare Part D Prescription Drug Plan to your coverage.
It’s important for you to know that if you remain without creditable drug coverage for 63 days or more after your Initial Enrollment Period ends, you may have to pay a late-enrollment penalty for Medicare Part D if you decide to add prescription drug coverage later. In Maine and the rest of the United States, this penalty is calculated using 1% of the national base beneficiary premium, and the number of full months you were eligible for Medicare Part D but didn’t enroll in a Medicare plan offering prescription drug coverage. This amount is then added to your Medicare Part D monthly premium. The national base beneficiary premium may increase each year, which means your late-enrollment penalty may also increase annually.
There may be many plan options available in Maine, depending on your zip code. A stand-alone Medicare Part D prescription drug plan can work alongside Original Medicare, Part A and Part B, to help cover costs for prescription drugs. A Medicare Advantage Prescription Drug plan, on the other hand, combines health and prescription drug coverage into a single plan. In addition to prescription drug coverage, Medicare Advantage plans offer at least the same coverage as Original Medicare (with the exception of hospice care, which continues to be covered under Part A), and sometimes include extra benefits, such as routine vision or hearing coverage, all in a single plan.
When comparing Medicare plans offering prescription drug coverage in Maine, it’s important to take into consideration your personal prescription drug needs. Make sure your medications are included in the formulary of the plan you choose.
If you are enrolled in a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, it is advisable to review your coverage in the fall each year. Each fall, your plan must send you an Annual Notice of Change and an Evidence of Coverage notice that details the plan’s benefits for the forthcoming year as well as the changes in benefits between the current year and the forthcoming year. Medicare prescription drug plans in Maine and the rest of the United States are allowed to change their premiums, copayments, deductibles, and formularies each year. Make sure you understand whether your current plan is best suited to your health and budget needs in the coming year or change, if possible, to one that can better serve your ongoing prescription drug coverage needs.
For more information about Medicare in Maine, you can view the following resources: