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Medicare beneficiaries in Pennsylvania may have a choice of more than one way to get prescription drug coverage, including a stand-alone Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan. Costs for each plan may vary, but many require you to pay a monthly premium, annual deductible, and copayment or coinsurance.
Medicare Part D is the federal program designed to assist Medicare beneficiaries with prescription drug coverage, whether they live in Pennsylvania or elsewhere in the United States. However, you don’t receive your prescription drug coverage directly from Medicare. Instead, you receive these benefits from private insurance companies contracted with Medicare to offer prescription drug coverage. In Pennsylvania, as in other states, Medicare beneficiaries can sign up for a stand-alone Medicare Part D Prescription Drug Plan in addition to their Original Medicare, Part A and Part B, coverage, and, if desired, a Medicare Supplement (Medigap) plan.
In Pennsylvania, as in other states, each Medicare Prescription Drug Plan has its own list of covered prescription drugs. This list is called a formulary, and covered prescription drugs are placed in different tiers (or categories), with each tier having a different cost. In general, prescription drugs in the lowest tier will cost the least, while prescription drugs in the higher tier will cost you more. If your doctor believes that a medication in a higher tier is necessary to treat your health condition, and if the prescription drug is too expensive for you, you can ask your plan for a tiering exception in order to have a lower copayment for your medication. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Usually you have the option of choosing between brand-name and generic prescription drugs. According to the Food and Drug Administration, generic drugs are safe equivalent substitutes for brand-name drugs that use similar active ingredients and offer results similar to those of the brand-name originals. The significant difference is that generic drugs often cost much less than brand-name drugs, which may result in significantly lower out-of-pocket expenses for consumers. In certain 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 all such generic drug substitutions with your doctor.
Be aware that you could be subject to a lifetime late enrollment penalty for Medicare Part D, if at any time after your Initial Enrollment Period you remain without creditable drug coverage for 63 days or more and enroll in a Medicare prescription drug plan later. Creditable drug coverage is prescription drug coverage (for example, from an employer’s health plan) that pays at least as much as Medicare standard prescription drug coverage.
In Pennsylvania, as in other states, the late enrollment penalty is calculated using 1% of the national base beneficiary premium ($32.74 in 2020) 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. Remember that the national base beneficiary premium may increase each year, which means your late enrollment penalty may also increase.
It’s important for you to know that if you choose to enroll in a stand-alone Medicare Part D Prescription Drug Plan, you have to stay enrolled in Original Medicare and continue paying your premiums in order not to lose your health coverage.
As a Pennsylvania Medicare beneficiary, it’s important for you to understand the difference between a stand-alone Medicare Part D Prescription Drug Plan and a Medicare Advantage Prescription Drug plan:
There are several things that Pennsylvania Medicare beneficiaries may need to consider when choosing a Medicare plan with prescription drug coverage or deciding whether to switch plans. For example:
If you’re already enrolled in a Stand-alone Medicare Part D Prescription Drug Plan, it’s always a good idea to review your plan offerings at the end of the year, to track any important changes. In Pennsylvania, as in other states, prescription drug plans 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 which the plan mails you in the fall before the new benefits are effective the following January 1st.
To learn more about your Medicare options in Pennsylvania, you may review the following pages: