Medicare Part D refers to optional prescription drug coverage offered by private insurance companies contracted with Medicare, and it is designed to help Medicare beneficiaries cover prescription drug costs. As a Medicare beneficiary in Virginia, you may be able to get prescription drug coverage by enrolling in a stand-alone Medicare Part D Prescription Drug Plan.  Medicare Part D Prescription Drug Plan costs and availability may vary, depending on the insurance company providing the plan, the benefit coverage offered, and where in Virginia you live. You typically pay a monthly premium and may have an annual deductible, copayments and coinsurance when you’re enrolled in one of these plans.

How Medicare Part D works in Virginia

If you’re a Medicare beneficiary already enrolled or eligible to enroll in Medicare Part A and/or Part B, you may enroll in a stand-alone Medicare Part D Prescription Drug Plan if you live in the plan’s service area. You’re generally limited to certain enrollment periods, described below.

Each Medicare Part D Prescription Drug Plan has a formulary, which is a list of prescription drugs that the plan covers. In Virginia, as is common elsewhere, most Medicare Part D Prescription Drug Plans provide you some choices between brand-name drugs and generic drugs and include both in their formularies.  According to the U.S. Food and Drug Administration, generic drugs are prescription drugs that have the same active-ingredient formula as brand-name counterparts. Generic drugs usually cost less than the brand-name medications. The medications in the formulary may be grouped into different benefit categories called tiers, each with a different out-of-pocket cost. The lower tiers include the more affordable prescriptions drugs (typically including generic drugs), while the higher tiers include more expensive medications.  The formulary may change at any time.  If you are enrolled, you will receive notice of the change from your plan when necessary.

Many stand-alone Medicare Part D Prescription Drug Plans also have their own networks of participating pharmacies and a mail order pharmacy.  Your out-of-pocket costs are generally lower when you use the plan’s network pharmacies and/or fill your prescriptions for maintenance medications through the plan’s mail-order pharmacy.

You can first join a Medicare Part D prescription drug plan during your Medicare Initial Enrollment Period, which begins three months before you turn 65, includes your birth month, and ends three months after your birth month. You must also have Medicare Part A and/or Medicare Part B in order to sign up for Medicare Part D in Virginia. If you’re enrolled in Medicare due to a disability, you can join a Medicare Part D prescription drug plan in Virginia from three months before until three months after your 25th month of receiving disability benefits.

It’s important to consider that if you remain without creditable drug coverage (that is, coverage  that is as good as Medicare Part D prescription 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 in Virginia, as you would anywhere else in 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. 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.

If you already have Medicare prescription drug coverage, a good time to switch to a new plan may be during the Fall Open Enrollment Period, which runs from October 15 to December 7.

If you’re enrolled in a Medicare Advantage Prescription Drug plan in Virginia and decide to switch back to Original Medicare, Part A and Part B, you can make the change during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. You can add a stand-alone Medicare Part D Prescription Drug Plan to go alongside your Original Medicare coverage. You can also change from one Medicare Advantage plan to another during this Medicare Advantage Open Enrollment Period.

Comparing your choices for Medicare Part D prescription drug coverage in Virginia

As a Medicare beneficiary you may have a choice in the type of Medicare plan with prescription drug coverage you select. A Medicare Part D Prescription Drug plan is a stand-alone plan that can work in conjunction with your Medicare Part A and/or Part B to help cover your costs for prescription drugs. A Medicare Advantage Prescription Drug plan, on the other hand, combines health and prescription drug coverage into a single plan, offering at least the same coverage as Original Medicare plus Part D prescription drug coverage. A Medicare Advantage Prescription Drug plan may also include extra benefits like routine vision, hearing, and dental, all for a single premium. However, you must be enrolled in Medicare Part A and Part B to enroll in a Medicare Advantage Prescription Drug plan and continue paying your Medicare Part A (if applicable) and Part B premium(s). If you have only Medicare Part A or Part B (perhaps because you have coverage from an employer or former employer or union group health plan), or you prefer to have Original Medicare (Part A and Part B), a stand-alone Medicare Part D Prescription Drug Plan is the type of plan you might want to consider.

When comparing Medicare plans providing prescription drug coverage in Virginia, it’s important  to take into consideration your personal prescription drug needs, since it’s your prescription drug costs, not simply the premium, that contribute largely to your annual out-of-pocket prescription drug expenses. Consequently, you will want to make sure your medications are on a plan’s list of covered prescription drugs (formulary) before you enroll in the plan.

It may be wise to review your Medicare Part D Prescription Drug Plan at the end of each year, in order to determine if there were any changes to your coverage. Plans in Virginia and the rest of the United States are allowed to change their premiums, copayments, deductibles, and drug formularies every year.  You will receive notice of these changes in the Annual Notice of Changes and Evidence of Coverage the plan mails you in the fall before the new benefits are effective the following January 1st.

For additional information about Medicare in Virginia, please refer to the following resources: