Medicare Part D is a Medicare program that provides prescription drug coverage to Medicare beneficiaries. There are a couple of ways that Georgia Medicare beneficiaries can get prescription drug coverage through Part D: you can enroll in a stand-alone Medicare Part D Prescription Drug Plan, or sign up for a Medicare Advantage Prescription Drug plan. Costs for Georgia Medicare Prescription Drug Plans and Medicare Advantage plans might differ; these costs might include a monthly premium, annual deductible, and copayment or coinsurance. 

How Medicare prescription drug coverage works in Georgia

As a Medicare beneficiary in Georgia, as in the rest of the United States, you can sign up for a stand-alone Medicare Part D Prescription Drug Plan to work alongside your Original Medicare, Part A and Part B, coverage. Original Medicare provides only limited prescription drug coverage (for example, it may cover medications administered to you in a Medicare-approved hospital during an inpatient stay or clinic in certain situations) – but it doesn’t cover most of the prescriptions you’d normally take at home.

Alternatively, you may be able to receive your Medicare coverage – including prescription drug coverage – from a Medicare Advantage Prescription Drug plan, described later in this article. 

Understanding formularies under Medicare Part D Prescription Drug Plans

Each Medicare Prescription Drug Plan has its own distinct list of covered prescription drugs, called a formulary. It sorts all covered drugs into different tiers (or categories). Prescription drugs in the lowest tier will generally cost the least, while drugs in the higher tier cost more. If your doctor believes that an expensive, higher-tier drug is necessary to treat your health condition, she or he can request a tiering exception from your plan to get a lower copayment for your prescription drug.

Most Medicare Prescription Drug Plans let you choose between generic and brand-name prescription drugs. According to the Food and Drug Administration, generic drugs are safe copies of brand-name drugs that use similar active ingredients and offer similar results as brand-name drugs. Generic drugs generally cost less than brand-name drugs and may result in lower out-of-pocket expenses for Georgia Medicare beneficiaries. In some cases, the generic version of your brand-name prescription drug may not be available, but there may be a similar generic drug that could work just as well for your particular condition. Be sure to discuss your prescriptions or suggested substitutions with your doctor or health-care provider. 

Eligibility and enrollment for Medicare Prescription Drug Plans

To sign up for a Georgia stand-alone Medicare Part D Prescription Drug Plan:

  • You must either have or be eligible to enroll in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance).
  • You must permanently reside in the service area of your plan.

In Georgia, as in other states, you can enroll in a stand-alone Medicare Prescription Drug Plan during the seven-month period starting three months before you turn 65, including your birth month, and ending three months after you turn 65. This is called your Medicare Initial Enrollment Period. If you’re enrolled in Medicare due to a disability, your seven-month Initial Enrollment Period usually starts three months before your 25th month of receiving disability benefits, includes the 25th month, and ends three months after.

Be aware that you will be subject to a late-enrollment penalty for Medicare Part D in Georgia, if at any time after your Initial Enrollment Period is over you remain without creditable drug coverage for 63 days in a row or longer. Creditable drug coverage is insurance that pays at least as much as a Medicare Part D Prescription Drug Plan would be expected to pay.

The late-enrollment penalty is calculated using 1% of the national base beneficiary premium ($33.06 in 2021) and the number of full months you were eligible for Medicare prescription drug coverage but didn’t enroll. This amount is added to your Medicare Part D monthly premium for as long as you have Medicare Part D. The national base beneficiary premium may increase each year, which means your late-enrollment penalty may also increase.

As a Georgia Medicare beneficiary, you can also enroll in a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan during the Annual Election Period from October 15 to December 7 each year. You are also able to change your Medicare Part D Prescription Drug Plan or Medicare Advantage plan during that period, or make other coverage changes.

If you’re enrolled in a Medicare Advantage plan and decide to drop it and return to Original Medicare instead, you can do so during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. You also have until March 31 to add an optional stand-alone Medicare Part D Prescription Drug Plan to your health insurance coverage or change to a different Medicare Advantage Prescription Drug Plan.

Types of Medicare Prescription Drug Plans in Georgia

Georgia Medicare beneficiaries have options for prescription drug coverage:

  • A stand-alone Medicare Part D Prescription Drug Plan is a plan you can sign up for in addition to Original Medicare to help with prescription drug costs. When you’re enrolled in a stand-alone Medicare Part D Prescription Drug Plan, you have to pay the plan’s premium (if any) in addition to your Original Medicare premium(s).
  • Medicare Advantage Prescription Drug plan, on the other hand, combines health and prescription drug coverage into one insurance plan, offering at least the same coverage as Original Medicare (and sometimes additional benefits such as routine vision, hearing, and dental), all in a single plan. You need to continue paying your Part B premium.

Here are some things that Georgia Medicare beneficiaries need to consider when choosing a Medicare Prescription Drug Plan:

  • First, see if the plan covers your individual prescription drug needs – check the plan’s formulary to see if your medications are listed. The formulary may change at any time. You will receive notice from your plan when necessary.
  • Then, consider the costs of various Medicare Prescription Drug Plans, such as premiums and deductibles.
  • Review the plan’s coverage gap benefits. The Medicare Part D coverage gap, or “donut hole,” is where Medicare may include less coverage after you’ve spent a certain amount that year, up to a certain limit, when “catastrophic” coverage applies.
  • If you’re already enrolled in a Georgia Medicare Prescription Drug Plan, it’s always a good idea to review your plan details at the end of the year, to be aware of any changes. Medicare Prescription Drug Plans can change their premiums, copayments, deductibles, and drug formularies every year, so the plan you’re currently enrolled in may not be the one best suited to your health needs the following year.
  • In addition, your health may change over the coming year, so be sure to always keep in mind your expected future medication needs when selecting a Medicare Prescription Drug Plan.