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Medicare Part D Prescription Drug Plans in North Carolina

October 6, 2016

Medicare Part D is government-sponsored private insurance intended to help Medicare beneficiaries get coverage for their prescription drug costs. As a Medicare beneficiary in North Carolina, you may be eligible to enroll in a stand-alone Medicare Part D Prescription Drug Plan. While Medicare Part D Prescription Drug Plans in North Carolina typically provide coverage for commonly prescribed medications used by Medicare beneficiaries, they may vary in their service areas, their prescription drug benefits, and their premiums.

How Medicare Part D Prescription Drug Plans work in North Carolina

If you’re a Medicare beneficiary in North Carolina, you may be receiving health coverage through Original Medicare, Part A (hospital insurance) and Part B (medical insurance), or a Medicare Advantage (Medicare Part C) plan without prescription drug coverage. If so, you may also want to enroll in a stand-alone Medicare Part D Prescription Drug Plan to obtain prescription drug benefits. 

Each Medicare Part D Prescription Drug Plan in North Carolina has a formulary, which is a list of covered drugs.  Often, a Part D Prescription Drug Plan groups medications within its formulary into different benefit categories, or tiers. Medications that are assigned to a particular tier, share the same benefit coverage. However, the member cost-share (copayment or coinsurance amount) is different for medications assigned to different tiers. Typically, the top tier includes the costlier drugs, while the bottom tier includes the most affordable medications.

In general, Medicare Part D Prescription Drug Plans in North Carolina allow you to choose between brand-name drugs and generic drugs in their formularies, often including many generic drugs in the lower tier. Generic drugs have the same active ingredients as brand-name drugs, at the same strength, dosage, and with the same method of administration, as defined by the Food and Drug Administration (FDA). In addition, the FDA requires that generics are tested to have the same results as brand-name drugs. Generic drugs generally cost less than their brand-name counterparts, offering additional cost-savings to Medicare beneficiaries.

The formulary and tiers play a significant role in determining the coverage of a prescribed medication.  Sometimes, however, upon request, the plan may make exceptions—for example, a plan may make a tiering exception to cover a higher-tier medication at a lower tier cost-share when a prescribing physician explains that a medication on a higher tier is medically necessary to treat a person’s health condition and that a similar medication on a lower tier cannot be tolerated by the person.  Or a plan may provide a generic drug substitute to a prescribed brand-name medication to help make the medication cost more affordable for the individual.

Also, a Part D Prescription Drug Plan’s formulary may change at any time. If enrolled, you will receive notice from your plan when necessary.

Getting Medicare Part D prescription drug coverage in North Carolina

To enroll in a Medicare Part D Prescription Drug Plan in North Carolina, you must either have Original Medicare, Part A and/or Part B.  You are also required to reside in the North Carolina service area of the Medicare Part D Prescription Drug Plan you select.

If you’re enrolled in Medicare due to a disability, you can enroll in a Medicare Part D Prescription Drug Plan in North Carolina from three months before until three months after your 25th month of disability. In most other cases, you may enroll in a Medicare Part D Prescription Drug Plan during your 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 may enroll in a Medicare Part D Prescription Drug Plan in North Carolina is during the Annual Election Period for Medicare Advantage and Medicare prescription drug coverage, which runs from October 15 to December 7 each year. And you can switch Prescription Drug Plans during the same period.

You can also sign up for Medicare Part D Prescription Drug Plans in North Carolina during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. If you disenroll from a Medicare Advantage plan during this period and return to Original Medicare, Part A and Part B, you can add a stand-alone Part D Prescription Drug Plan through February 14 as well.

Timing for enrollment is important.  If you go without creditable drug coverage (that is, prescription drug insurance that is at least as good as Medicare Part D )for 63 days or more after your Initial Enrollment Period ends, you may be liable for a late-enrollment penalty for as long as you remain enrolled in Medicare Part D. The 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. 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.

Also keep in mind that if you sign up for a Medicare Part D Prescription Drug Plan in North Carolina, you have to remain enrolled in Medicare and pay any applicable Part A and/or Part B premiums (if you’re not entitled to premium-free Medicare Part A coverage), in order to keep your insurance coverage.

Choosing a Medicare Part D Prescription Drug Plan in North Carolina

You may have a number of Medicare Part D Prescription Drug Plan options available where you live in North Carolina. A Medicare Part D Prescription Drug Plan is a stand-alone plan that Medicare beneficiaries get to go alongside Original Medicare, Part A and Part B, to help cover costs for prescription drugs. A Medicare Advantage Prescription Drug plan combines health and prescription drug coverage into a single plan and offers at least the same coverage as Original Medicare. Medicare Advantage Prescription Drug plans in North Carolina may offer additional benefits, like routine vision, hearing, and dental, all for a single premium.

When comparing Medicare Part D Prescription Drug Plans in North Carolina, it’s a good idea to take into consideration your individual prescription drug needs. Remember that it’s your drug cost, rather than your premiums or deductible, that can contribute significantly to your out-of-pocket expenses.

You may also want to review your Medicare Part D Prescription Drug Plan on an annual basis, in case there are any changes to your coverage. Medicare Part D Prescription Drug Plans in North Carolina, like those in the rest of the United States, are permitted to change their premiums, copayments, deductibles, and drug formularies every year, which means that your present Prescription Drug Plan may not provide the best fit for your health needs the following year. You may even want to shop for a new plan every year during the Annual Election Period.

For more information about Medicare in North Carolina, view the following resources: