Last Updated on
October 6, 2016
The Medicare Part D program makes prescription drug benefits available to Medicare beneficiaries in New York and throughout the United States. The cost of Medicare Part D Prescription Drug Plans varies across the state of New York, but most require payment of a monthly premium, annual deductible, and copayments or coinsurance.
If you’re a Medicare beneficiary in New York, you may be receiving health coverage through Original Medicare (which includes Part A and Part B), or a Medicare Advantage (Medicare Part C) plan that covers health benefits only. Neither of these Medicare insurance options provide prescription drug coverage except for in cases of an inpatient hospital stay. However, Medicare prescription drug coverage is available from Medicare Part D Prescription Drug Plans, which are offered by private insurance companies contracted with Medicare. These plans can work alongside your Original Medicare or Medicare Advantage plan coverage. (You cannot have Medicare prescription drug coverage from both a Medicare Advantage Prescription Drug plan and a stand-alone Part D Prescription Drug Plan simultaneously.)
Each Medicare Part D Prescription Drug Plan in New York has a list of covered prescription drugs called a formulary. Many Prescription Drug Plans divide their formularies of covered prescription drugs into tiers (or categories), with each tier having a distinct cost-share, which is the amount the plan member pays out-of-pocket for the medication. So, for example a Prescription Drug Plan may have a generic and a brand name covered drug on two different tiers. Typically the generic medication is on a tier with a lower out-of-pocket cost than the brand name drug.
In New York, as in the rest of the United States, Medicare Part D Prescription Drug Plans generally allow you to choose between brand-name drugs and generic drugs. The Food and Drug Administration (FDA) describes generic drugs as using the same active ingredients as brand-name drugs, at the same strength, dosage, and with the same method of administration. The FDA requires generics to be tested as having the same results as brand-name drugs. Generic drugs often cost less than their brand-name equivalent, resulting in cost savings for Medicare beneficiaries.
If you are eligible for Medicare coverage, you are also eligible for the Medicare drug benefit (Part D). You must be enrolled in Medicare Part A and/or Part B to enroll in a Medicare Part D Prescription Drug Plan.
If you’re enrolled in Medicare due to a disability, you can enroll in a Medicare Part D Prescription Drug Plan in New York from three months before until three months after your 25th month of disability. In most other instances, you can enroll in a Part D Prescription Drug Plan during your seven-month Medicare Initial Enrollment Period, which begins three months before you turn 65, includes your birthday month, and ends three months after that month.
Another time you can sign up for a Medicare Part D Prescription Drug Plan is during the annual fall Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage, which runs from October 15 to December 7. You can switch Medicare Part D Prescription Drug Plans during this period.
You may be able to enroll in a Medicare Part D Prescription Drug Plan during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. If you disenroll from a Medicare Advantage Prescription Drug plan during this period and return to Original Medicare, you can add a stand-alone Medicare Part D Prescription Drug Plan through February 14.
The best time for you to enroll in a plan that provides Medicare Part D prescription drug coverage is when you are first eligible for Medicare benefits. An exception to this general rule of thumb is a situation in which you already have prescription drug coverage through another insurance that is equivalent to Medicare Part D coverage. In this instance, you have creditable prescription drug coverage.
Be aware, however, that if you go without creditable drug coverage for 63 days or more after your Initial Enrollment Period ends, you may be liable for a late-enrollment penalty if you enroll in a Medicare Prescription Drug Plan later, and you will continue to pay this late-enrollment penalty for as long as you have Medicare Part D prescription coverage. The Medicare Part D late-enrollment 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 plan offering Medicare prescription 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.
In New York, as in the rest of the United States, you are required to reside in the service area of your chosen Medicare Part D Prescription Drug Plan. If you join a Medicare Part D Prescription Drug Plan, you have to remain enrolled in Medicare and continue to pay any Part A or Part B premium you owe in addition to the premium you pay for your Medicare prescription drug benefits in order to keep your insurance coverage. You may be eligible for Extra Help paying some of your out-of-pocket expenses related to Medicare Part D prescription drug benefits.
You may have choices among the Medicare Part D Prescription Drug Plans that are available where you live in New York. Medicare Part D Prescription Drug Plans cover prescription drugs frequently used by Medicare beneficiaries. However, there can be differences in prescription drug benefits between plans. Each Medicare Part D Prescription Drug Plan can decide which medications to cover, and many Part D Prescription Drug Plans place these covered medications into different cost-sharing tiers or categories. Cost-sharing refers to the amount of out-of-pocket cost you pay each time you fill your prescription, and this amount can be different for each medication you take if the plan assigns the medications to different tiers.
To help you understand your prescription drug benefits, Medicare Part D Prescription Drug Plans publish a current list of medications they cover, often referred to as a formulary. While the formulary may change at any time, you will receive notice from your plan when necessary. The formulary tells you what medications the plan covers and at what cost-sharing tier they are placed.
Before you choose a Medicare Part D Prescription Drug Plan be sure to consider your individual prescription needs. Your cost-share for medications may be as significant, if not more significant, a factor in your expenses as your monthly premium. Therefore, check to see that your medications are on a Medicare Part D Prescription Drug Plan’s formulary before you enroll.
It may also be smart to re-examine your Medicare Part D Prescription Drug Plan on an annual basis, in case there have been changes to your drug coverage. Medicare Part D Prescription Drug Plans in New York, as in the rest of the United States, are allowed to change their premiums, copayments, deductibles, and drug formularies each year, which means that your present plan may not provide the best fit for your needs next year. You may even want to compare Medicare Part D Prescription Drug Plans every year during the Annual Election Period.
For additional details about Medicare in New York, see the following pages: