Last Updated on
October 6, 2016
Medicare Part D is a federal program providing Medicare beneficiaries prescription drug coverage through private insurance companies that contract with Medicare. Original Medicare, Part A (hospital insurance) and Part B (medical insurance), may cover certain prescription drugs in limited situations (such as when you’re a hospital inpatient, or when you receive medications in an outpatient office setting), but generally doesn’t cover most prescriptions you would take at home.
As a Medicare beneficiary living in South Carolina, you may be able to receive Medicare prescription drug benefits from a stand-alone Medicare Part D Prescription Drug Plan, or through a Medicare Advantage Prescription Drug plan. Medicare Prescription Drug Plan costs and availability may vary, depending on the insurance company offering the plan, the benefit coverage offered, and where you live. You might pay a monthly premium and may have an annual deductible, copayments and coinsurance when you’re enrolled in one of these plans.
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 as long as you live in the plan’s service area. If you prefer to receive your Medicare Part A and Part B benefits through a Medicare Advantage Prescription Drug plan, you need to be enrolled in both Part A and Part B. (Under Medicare Advantage plans, hospice care is still covered directly under Medicare Part A.)
Each Medicare Prescription Drug Plan has a formulary, which is a list of prescription drugs that the plan covers. In South Carolina, most Medicare Prescription Drug Plans may give you some choices between brand-name drugs and generic drugs and include both in their formularies. The same is true in the other states. 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. You will receive notice of the change from your plan when necessary.
Many Medicare Prescription Drug Plans also have their own networks of participating pharmacies and mail order pharmacies. 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 enroll in a Medicare Part D prescription drug plan during your Medicare Initial Enrollment Period, which generally begins three months before you turn 65, includes your birth month, and ends three months after your birth month. If you’re enrolled in Medicare due to a disability, you can generally enroll in a Medicare Part D prescription drug plan in South Carolina 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, on average, 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 South Carolina, 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 want to sign up for a Medicare Prescription Drug Plan after your Initial Enrollment Period is over, or you’d like to switch plans, typically a good time to do so is during the Annual Election Period. This period runs from October 15 to December 7. If you’re enrolled in a Medicare Advantage Prescription Drug plan in South Carolina and decide to switch back to Original Medicare, Part A and Part B, you can make the change during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. You may add a stand-alone Medicare Part D Prescription Drug Plan to your coverage during this time.
As a Medicare beneficiary you may have a choice in the type of Medicare plan with prescription drug coverage you select. A stand-alone Medicare Part D Prescription Drug plan can work in conjunction with your Medicare Part A and/or Part B coverage 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 (except hospice care, which Part A still covers). A Medicare Advantage Prescription Drug plan may also include additional benefits like routine vision, hearing, and dental services, all for a single premium. However, you must continue paying your Medicare Part B premium, in addition to any premium your Medicare Prescription Drug Plan may charge.
Plans offering Medicare Part D prescription coverage may have different costs. Premiums, deductibles, copayments, and coinsurance are likely to vary. When comparing Medicare plans providing prescription drug coverage in South Carolina, it may be wise 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. Therefore, it may be a good idea to make sure your medications are on a plan’s list of covered prescription drugs (formulary) before you enroll in the plan. The formulary may change at any time. You will receive notice of the change from your plan when necessary.
If you are concerned you may not be able to afford Medicare prescription drug coverage, you may be interested in learning more about the Part D Extra Help program, which provides assistance in paying Medicare beneficiaries’ prescription drug costs. To be eligible you must be enrolled in Medicare and generally must have a limited amount of income and personal assets. To learn more about this program, you may contact the Insurance Counseling Assistance and Referrals for Elders program (I-CARE), South Carolina’s state health insurance assistance program.
It also may be wise to review your Medicare Prescription Drug Plan at the end of each year, in order to determine if there were any changes to your coverage. Plans in South Carolina 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 which the plan mails you in the fall before the new benefits are effective the following January 1st.
For additional information about Medicare in South Carolina, you may refer to the following resources: