Medicare Advantage is a type of Medicare plan that is offered by Medicare-contracted private insurance companies as another way to get your Medicare coverage. Some of these plans combine health insurance benefits and prescription drug coverage into one comprehensive package called a Medicare Advantage Prescription Drug (MAPD) plan.
Medicare Advantage Prescription Drug plans, like all Medicare Advantage plans, are required to cover everything that Original Medicare (Part A and Part B) covers, with the exception of hospice care, which is still covered by Part A of Original Medicare. In addition to Medicare Part D prescription drug coverage, many of these plans can include other benefits such as routine vision and dental, hearing, and access to wellness programs (like Silver Sneakers, for example).
Types of Medicare Advantage Prescription Drug plans
There are several types of Medicare Advantage Prescription Drug plans: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO*), Medicare Savings Account (MSA), Private Fee-For-Service (PFFS), and Special Needs Plans (SNP). Each of these plans may have different rules regarding how you can receive care. For example, HMO plans require enrollees to stay within its network of providers when receiving medical care. Visiting an out-of-network provider may mean you pay the full costs for that care (with the exception of emergency care).
Keep in mind that if you’re interested in getting prescription drug benefits with your Medicare Advantage plan, you should generally enroll in a Medicare Advantage Prescription Drug plan if available, not a stand-alone Medicare Prescription Drug Plan. Medicare Prescription Drug Plans are generally meant to work alongside Original Medicare, not a Medicare Advantage plan. In fact, if you enroll in a Medicare Prescription Drug Plan while you’re already in a Medicare Advantage plan with prescription benefits, you’ll be automatically disenrolled from the Medicare Advantage plan and returned to Original Medicare – so it’s important to understand how your actions might affect your coverage.
The exception is if you’re enrolled in certain types of Medicare Advantage plans that don’t cover prescription drugs, such as Medicare Savings Account plans or certain Private Fee-for-Service plans. In this case, you’re allowed to enroll in a stand-alone Medicare Prescription Drug Plan for your Part D coverage.
Special Needs Plans are another type of Medicare Advantage plan that you may have available to you. These plans limit enrollment to beneficiaries who meet certain criteria, such as having a chronic or disabling condition; having both Medicare and Medicaid coverage; or living in an institution (such as a nursing home). Unlike other types of Medicare Advantage plans, Special Needs Plans always include prescription drug benefits and often cover medications that are tailored to the health needs of their members. For example, a Chronic-Condition Special Needs Plan for cancer patients may cover the most commonly prescribed anti-cancer medications.
Medicare Advantage Prescription Drug plan formulary
Each Medicare Advantage Prescription Drug plan has a documented list of prescription medications that it covers, called a formulary. Medicare Advantage plans that include prescription drug coverage generally must offer two or more medications within each category (e.g. antidepressant, antibiotic), and the prescriptions are placed into tiers that then determine cost sharing. For example, generic prescriptions are often in a lower tier (and often come with lower copayment and coinsurance costs), while brand-name drugs are placed into a higher tier (and usually have higher out-of-pocket costs). Before enrolling in a Medicare Advantage Prescription Drug plan, it’s a good idea to make sure that all of your current prescriptions are included in the plan’s formulary, since covered medications and costs can vary from plan to plan. Two plans may cover the same prescription drugs with very different out-of-pocket costs, so taking the time to research plan options can save you money.
Keep in mind that formularies may change at any time. The Medicare plan will notify you if necessary.
Medicare Advantage Prescription Drug plan costs
As mentioned, Medicare Advantage Prescription Drug plans are offered through Medicare-approved private insurance companies, meaning that the plan costs can vary. Medicare Advantage Prescription Drug plans will generally charge a monthly premium, although some service areas may offer plans with premiums as low as $0 a month. (Keep in mind that even if your Medicare Advantage plan has a $0 premium, you’re still responsible for your Part B premium.) Beneficiaries must also pay for additional costs, such as copayments, coinsurance, and deductibles.
Enrolling in a Medicare Advantage Prescription Drug plan
You’re eligible to enroll in a Medicare Advantage plan if you have both Medicare Part A and Part B, live within the plan’s service area, and don’t have end-stage renal disease (ESRD), with some exceptions. You can generally only enroll in Medicare Advantage plans during certain times of the year: either during your Initial Coverage Election Period when you’re first eligible for Medicare Part C; the Annual Election Period (AEP); or Special Election Periods at any time of the year that you have a qualifying situation. We’ll go through each of these periods below.
You’re first eligible to enroll in a Medicare Advantage plan during your Initial Coverage Election Period, which is the seven-month period surrounding when you’re first eligible for Medicare. For most people, this period coincides with their Initial Enrollment Period for Part B and starts three months before they turn 65, includes their birthday month, and ends three months later. If you qualify for Medicare due to disability, your Initial Coverage Election Period would start three months before your 25th month of Social Security or Railroad Retirement Board disability benefits and continue for seven months.
If you missed your Initial Coverage Election Period or didn’t enroll in a Medicare Advantage plan at this time, you have a yearly opportunity to do so. The Annual Election Period (October 15 to December 7) is the time when you’ll have the most flexibility to make changes to your Medicare coverage. Whether you’re enrolling in a Medicare Advantage plan for the first time or already have Medicare Part C but would like to switch to a plan that includes prescription drug benefits, you can do so then. Also known as the Fall Open Enrollment, you can make the following changes during this period:
- Enroll in a Medicare Advantage plan.
- Switch Medicare Advantage plans.
- Disenroll from a Medicare Advantage plan and return to Original Medicare.
- If you have Original Medicare, you can enroll in a Medicare Prescription Drug Plan, switch plans, or disenroll from a stand-alone plan.
After the Fall Open Enrollment has passed, you’ll have less flexibility to make changes to your Medicare coverage except in certain situations. If you change your mind and want to go back to Original Medicare, you can use the Medicare Advantage Open Enrollment Period (January 1 to March 31) to do so. If you disenroll from your Medicare Advantage plan during this time, you can also use this period to enroll in a stand-alone Medicare Prescription Drug Plan, which works alongside Original Medicare to provide s prescription drug coverage.
In certain situations, you may be able to make changes outside of the regular election periods with a Special Election Period. Some examples of qualifying situations include, but aren’t limited to: Moving out of your plan’s service area, being eligible for the Extra Help program, or being a dual eligible (meaning you get both Medicare and Medicaid benefits).
As mentioned, Medicare Advantage Prescription Drug plan costs and coverage details can change on an annual basis, so it is recommended that you compare plan options in your area each year.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.