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Medicare Prescription Drug Plans in Pennsylvania

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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.

How Medicare prescription drug coverage works in Pennsylvania

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.

Formularies

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.

Eligibility and enrollment

  • To enroll in a stand-alone Medicare Part D Prescription Drug Plan, you must either have, or be eligible to receive Medicare Part A(hospital insurance) and/or Medicare Part B (medical insurance), and you must live in the service area of your drug plan.
  • To enroll in a Medicare Advantage Prescription Drug plan, you must be enrolled in Medicare Part A and Part B.
  • In Pennsylvania, as in other states, you can enroll in a stand-alone Medicare Part D Prescription Drug Plan, or a Medicare Advantage plan, during the seven-month Medicare Initial Enrollment Period, which begins 3 months before your birthday month, includes your birthday month and ends 3 months after your birthday month.
  • If you’re enrolled in Medicare due to a disability, you can enroll in a Medicare Prescription Drug Plan during the time frame that begins three months before your 25thmonth of receiving disability benefits from the Social Security Administration or the Railroad Retirement Board and ends three months after your 25th month of disability.
  • As a Pennsylvania Medicare beneficiary, you can also enroll in a Medicare Prescription Drug Plan during the Annual Election Period, which runs from October 15 to December 7 each year. You can also switch Stand-alone Medicare Part D Prescription Drug Plans during that period.
  • If you’re enrolled in a Medicare Advantage plan and decide to switch to Original Medicare, you might be able to 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 a stand-alone Medicare Part D Prescription Drug Plan to your health insurance coverage; this is optional, but lets you avoid going without prescription drug coverage and enables you to avoid a Part D late enrollment penalty.

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.

Types of Medicare prescription drug plans in Pennsylvania

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:

  • A stand-alone Medicare Part D Prescription Drug Plan is coverage beneficiaries generally choose in addition to Original Medicare to receive help with their prescription drug costs. When you’re enrolled in Medicare Part D Prescription Drug Plan, you may have to pay the plan’s monthly premium in addition to your Original Medicare premiums.
  • A Medicare Advantage Prescription Drug plan, on the other hand, combines health and prescription drug coverage into one plan, offering at least the same coverage as Original Medicare (except for hospice care, which remains covered by Medicare Part A), and sometimes additional benefits such as routine vision, hearing, and dental, all in a single plan. With a Medicare Advantage Prescription Drug plan, you still continue paying your Medicare Part B premium and the plan’s premium, if any.

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:

  • Compare each plan’s formulary of covered prescription drugs with regard to your individual prescription drug needs. This is important because it can be your prescription drug costs–not your premiums or deductible–that may significantly impact your out-of-pocket expenses.

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: