Last Updated on
October 6, 2016
In Wisconsin, Medicare beneficiaries may be able to get prescription drug coverage by enrolling in a stand-alone Medicare Part D Prescription Drug Plan to work alongside their Original Medicare coverage. The following discussion provides information about this option for receiving Medicare Part D prescription drug benefits.
If you’re a Medicare beneficiary in Wisconsin, you may be receiving health coverage through Original Medicare (which includes Part A and Part B), or a Medicare Advantage plan that covers health benefits only. Neither of these Medicare insurance options provides prescription drug coverage except in cases of an inpatient hospital stay, or in certain other cases – for example, a clinic setting where a prescription drug must be administered by a professional health-care provider. However, Medicare prescription drug coverage is available from Medicare Advantage Prescription Drug plans, which include Part A and Part B health benefits (except for hospice care, which Part A still covers) and prescription drug coverage. Or, you can stay with Original Medicare and enroll in a stand-alone Medicare Part D Prescription Drug Plan. Both types of Medicare plans with Part D prescription drug coverage are offered by private insurance companies contracted with Medicare.
If you are interested in a Medicare Advantage Prescription Drug plan, however, you must have Part A and Part B to enroll. You may enroll in a stand-alone Medicare Part D Prescription Drug Plan if you have either Part A or Part B, or both. Stand-alone Medicare Part D Prescription Drug Plans can work in conjunction with your Original Medicare coverage. Otherwise, the two different types of Medicare plans with prescription drug coverage have very similar features. You will choose from among plans that are available where you live if you are interested in receiving Medicare Part D prescription drug coverage.
Each Medicare Part D Prescription Drug Plan in Wisconsin has a list of covered prescription drugs called a formulary. Many Prescription Drug Plans organize their formularies into tiers (or categories), with each tier having a distinct cost-share, which is the amount the plan member pays out-of-pocket for the medication. For example a Medicare Part D Prescription Drug Plan may have a generic and a brand name covered drug on two different tiers. Typically the generic medication is on a tier with a lower out-of-pocket cost than the brand name prescription drug. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
In Wisconsin, as in the rest of the United States, Medicare Part D Prescription Drug Plans generally allow you to choose between brand-name drugs and generic drugs. The Food and Drug Administration (FDA) describes generic drugs as using the same active ingredients as brand-name drugs, at the same strength, dosage, and with the same method of administration. The FDA requires generics to be tested as having the same results as brand-name prescription drugs. Generic drugs often cost less than their brand-name counterparts, resulting in potential cost savings for Medicare beneficiaries.
If you are eligible for Medicare coverage, you are also eligible for the Medicare prescription drug coverage (Part D). You must be enrolled in Medicare Part A and/or Part B to enroll in a stand-alone Medicare Part D Prescription Drug Plan.
If you’re enrolled in Medicare due to a disability, you can enroll in a stand-alone Medicare Part D Prescription Drug Plan in Wisconsin from three months before until three months after your 25th month of receiving disability benefits from the Social Security Administration or the Railroad Retirement Board. In most other instances, you can enroll in a Part D Prescription Drug Plan during your seven-month Medicare Initial Enrollment Period, which begins three months before you turn 65, includes your birthday month, and ends three months after that month.
Another time you can sign up for a Medicare Part D Prescription Drug Plan is during the Annual Election Period for Medicare Advantage and Medicare prescription drug coverage, which runs from October 15 to December 7. You can switch Medicare Part D Prescription Drug Plans during this period as well.
You may be able to enroll in a Medicare Part D Prescription Drug Plan during the annual Medicare Advantage Disenrollment Period, which runs from January 1 to February 14. If you disenroll from a Medicare Advantage Prescription Drug plan during this period and return to Original Medicare, you can add a stand-alone Medicare Part D Prescription Drug Plan through February 14.
The best time for you to enroll in a plan that provides Medicare Part D prescription drug coverage is when you are first eligible for Medicare benefits. An exception to this general rule is a situation in which you already have prescription drug coverage through another insurance plan that is equivalent to Medicare Part D coverage. In this instance, you have creditable prescription drug coverage.
Be aware, however, that if you go without creditable drug coverage for 63 consecutive days or more after your Initial Enrollment Period ends, you may be liable for a Part D late-enrollment penalty if you enroll in a Medicare Prescription Drug Plan later, and you will continue to pay this late-enrollment penalty for as long as you have Medicare Part D prescription coverage. The Medicare Part D late-enrollment 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 in a plan offering Medicare prescription coverage. 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 enroll in a stand-alone Medicare Part D Prescription Drug Plan, or in a Medicare Advantage Prescription Drug plan, you have to remain enrolled in Medicare and continue to pay any applicable Part A or Part B premium in addition to the premium you pay for your Medicare prescription drug benefits.
If you are concerned that you won’t be able to afford prescription drug coverage, you may wish to check to see whether you are eligible to participate in the Extra Help program. This program is designed to assist Medicare beneficiaries in Wisconsin and elsewhere pay their prescription drug costs. To be eligible, a beneficiary must be enrolled in Medicare and must have a limited amount of income and personal assets. To learn more about the Extra Help program, you may contact the Social Security Administration on line or by visiting your local Social Security office. You may also want to investigate whether you are eligible for the Wisconsin SeniorCare Program, which is considered “creditable coverage”, or an acceptable alternative to Medicare Part D coverage. You may decide to enroll in one or both. If you enroll in both a stand-alone Medicare Part D Prescription Drug Plan and SeniorCare, SeniorCare will coordinate benefits with your Medicare plan providing prescription drug coverage.
For more information about Medicare and other health-related programs, see the Wisconsin Department of Health Services web page.
You may have choices among the stand-alone Medicare Part D Prescription Drug Plans available where you live. Medicare Part D Prescription Drug Plans cover prescription drugs frequently used by Medicare beneficiaries. However, there can be differences in prescription drug benefits among plans. Each Medicare Part D Prescription Drug Plan determines which medications it covers and their cost-sharing tiers or categories. Cost-sharing refers to the amount of out-of-pocket cost you pay each time you fill your prescription, and this amount can be different for each medication you take if the plan assigns the medications to different tiers.
To help you understand your prescription drug benefits, all Medicare Part D Prescription Drug Plans publish a current list of medications they cover, often referred to as a formulary. While the formulary may change at any time, you will receive notice from your plan when necessary. The formulary tells you what medications the plan covers and in which cost-sharing tier they are placed.
Before you choose a Medicare Part D Prescription Drug Plan be sure to consider your individual prescription needs. Your out-of-pocket costs for medications may be as significant, if not more significant, a factor in your expenses as your monthly premium. Therefore, check to see that your medications are on a Medicare Part D Prescription Drug Plan’s formulary before you enroll.
It is also wise to re-examine your Medicare Part D Prescription Drug Plan on an annual basis, in case there have been changes to your drug coverage. Medicare Part D Prescription Drug Plans in Wisconsin, as in the rest of the United States, are allowed to change their premiums, copayments, deductibles, and drug formularies each year, which means that your present plan may not provide the best fit for your needs next year. It’s a good idea to review two documents your plan mails to you each fall: the Annual Notice of Changes and the Evidence of Coverage. These documents explain any changes in plan benefits for the coming year. The documents are also posted on the plan’s web site. You may even want to compare Medicare Part D Prescription Drug Plans every year during the Annual Election Period.
When you are ready to start comparing Medicare Part D Prescription Drug Plans in Wisconsin, you may enter your zip code in the plan finder on this page for a customized list of plans available in your county of residence.
If you would like to learn more about your Medicare options in Wisconsin, please visit the following pages: