Original Medicare, Part A and Part B, includes limited prescription drug coverage (such as when you might receive medication as a hospital inpatient); it doesn’t cover most medications you’d take at home. If you’re living in Washington, D.C. and need prescription drug coverage, you may want to learn about the Medicare Part D program. Under Part D, private insurance companies contract with Medicare to provide prescription drug coverage to Medicare beneficiaries. Costs associated with Medicare Part D Prescription Drug Plans in Washington, D.C. may vary; plans may charge a monthly premium, annual deductible, and copayment or coinsurance. Availability of these plans varies by zip code.
How Medicare Part D Prescription Drug Plans work in Washington, D.C.
Under Medicare Part D, each plan has its own list of covered prescription drugs, called a formulary. A formulary divides drugs into tiers, which are different categories, each with a different cost. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
The higher tiers list the more expensive medications, while the lower tiers include the more affordable drugs. If your doctor determines that a higher-tier drug is necessary for your medical condition instead of a similar drug in a lower tier, you or your prescriber can ask your plan for a tiering exception to see if you can pay less for your higher-tier medication. Your doctor or health provider must determine that the more expensive prescription drug is medically necessary for your treatment.
Most Medicare Part D Prescription Drug Plans include brand-name drugs and generic drugs in their formularies. According to Medicare.gov, generic drugs are copies of brand-name drugs, with similar active ingredients. The difference is that generic drugs are generally much more affordable than the corresponding brand-name versions. Also know that in certain cases, if your specific generic prescription drug is not available, you may be allowed to substitute a similar generic drug rather than paying more for a brand-name drug; however, first make sure you discuss all options and details with your doctor or health-care provider.
When can I sign up for Medicare Part D?
There are limited times when you can sign up for Medicare prescription drug coverage, and you need to meet eligibility requirements.
- In order to sign up for a stand-alone Medicare Part D Prescription Drug Plan, you must already be enrolled or eligible to enroll in Original Medicare, Part A or Part B.
- If you’d rather get your Medicare health and drug benefits through a Medicare Advantage Prescription Drug plan, you need both Medicare Part A and Part B to qualify, and you might not qualify if you have end-stage renal disease.
- Whether you get your Medicare prescription drug coverage through a stand-alone Medicare Part D Prescription Drug Plan or through Medicare Advantage, you must live within the plan’s service area.
- If you’re a Medicare beneficiary in Washington, D.C., as in the rest of the United States, you can sign up for a stand-alone Medicare Part D Prescription Drug Plan during your seven-month Medicare Initial Enrollment Period.
- If you sign up for a Medicare Advantage Prescription Drug plan, your Initial Coverage Election Period is generally the same as the Initial Enrollment Period mentioned above, unless you delay Medicare Part B enrollment.
- If you don’t sign up for Medicare prescription drug coverage when you’re first eligible, you can enroll under the Medicare Part D or the Medicare Part C program during the Annual Election Period, which runs from October 15 to December 7, and you may switch plans during that same period. If you don’t sign up for Medicare prescription drug coverage when you’re first eligible, you might have to pay a late-enrollment penalty when you do sign up.
- If you’re enrolled in a Medicare Advantage plan and decide to switch back to Original Medicare, you can do this during the Medicare Advantage Open Enrollment Period, from January 1 toMarch 31 , and you have until March 31 to add a stand-alone Medicare Part D Prescription Drug Plan to your coverage. You also can switch Medicare Advantage plans during this period.
- In certain situations, you can sign up for a Medicare Advantage plan or a stand-alone Medicare Part D Prescription Drug Plan during a Special Election Period. There are several such situations; one example is moving out of your plan’s service area.
Be aware that if you don’t have creditable prescription drug coverage for 63 consecutive days or more after your Initial Enrollment Period ends, you may be subject to a lifetime late-enrollment penalty under Medicare Part D if you get this coverage later. In Washington, D.C. 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. 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.
You need to continue paying your Medicare Part B premium no matter what type of Medicare plan you sign up for, if you have Medicare Part B. If you enroll in a stand-alone Medicare Part D Prescription Drug Plan, you don’t have to be enrolled in Part B; but Medicare Advantage requires you to have both Part A and Part B.
Types of Medicare Prescription Drug Plans in Washington, D.C.
As a Medicare beneficiary in Washington, D.C., you may have access to various Medicare Prescription Drug Plans. A stand-alone Medicare Part D Prescription Drug Plan can work alongside your Original Medicare, Part A and Part B, coverage to help cover prescription drug costs. A Medicare Advantage Prescription Drug plan combines health and prescription drug coverage into a single plan. Medicare Advantage plans must offer at least the same coverage as Original Medicare, Part A and Part B (except for hospice care, which Part A covers); most plans include prescription drug coverage. Some plans include extra benefits such as fitness programs or routine dental services.
When comparing Medicare Prescription Drug Plans in Washington, D.C., be sure to take into consideration your medication needs, since formularies and costs may vary among plans.
You might also want to review your Medicare Part D Prescription Drug Plan at the end of every year to be aware of any changes to your coverage. In Washington, D.C. and the rest of the United States, Medicare Prescription Drug Plans can change their premiums, copayments, deductibles, and drug formularies every year.
Read your plan’s Annual Notice of Change and its Evidence of Coverage to learn about the changes, and consider whether your medication needs have changed. Your current plan may not be the one best suited to your health needs in the coming year.
For more information about Medicare insurance in Washington, D.C., check out the following resources: