If you are eligible for Medicare and you don't have drug coverage through your employer, VA, or other source, additional prescription drug coverage is available to you through either:
(1) a stand-alone Medicare
Part D prescription drug plan (PDP
(2) a Medicare Advantage plan that includes
prescription drug coverage (MAPD
. . . And with both alternatives you would choose the specific drug plan
that provides the most economic drug coverage.
So what is the difference?
A Medicare Part D plan (PDP) only provides drug coverage. A Medicare Advantage (MAPD) plan provides Medicare Part D drug coverage - and also provides Medicare Part A (hospitalization and in-patient) coverage and Medicare Part B (doctor and out-patient) coverage and probably will include additional healthcare and non-healthcare benefits.
Tip: Have you had too much information already?
No problem, you can always call a Medicare representative at
1-800-633-4227 (1-800-Medicare) and someone will assist you with your
Medicare plan enrollment decision.
You can also telephone a SHIP representative
for assistance or speak with a local Medicare advocate - or you can keep reading for more information . . .
What drug coverage do PDPs and MAPDs have in common?
Some key differences between PDPs and MAPDs.
- Lower-cost prescriptions - A PDP and an MAPD both
provide Medicare drug coverage for a certain group of out-patient
prescription drugs where you should pay less for your prescriptions -
and avoid the late-enrollment premium penalty should you ever wish to have drug coverage in the future.
- Large list of covered drugs - Both Medicare drug plans
have a formulary or drug list that shows what brand and generic
prescriptions are covered by the plan (formularies will vary between
plans and can have anywhere between 2,000 to 4,000+ drugs).
- Large network of pharmacies - Both a Medicare PDP and an MAPD have a network of 50,000 to 60,000+ pharmacies where you can use the drug benefit.
- Cost-sharing for drugs - Both drug plans have different
cost-sharing for drugs on different levels or formulary "tiers" (for
example, you may have a $30 co-pay for a Tier 3 brand-name drug, a $2
co-pay for a Tier 1 generic drug, and pay 25% of retail for a Tier 4
- Same rules and procedures - Both plans are governed by
similar rules and you can move from one type of plan to another without
noticing much change in how your drug plan functions.
As noted, choosing how you receive Medicare drug coverage ultimately
depends on your situation and personal preferences - and whether you
need only prescription drug coverage or you wish to have prescription
drug coverage and additional healthcare coverage. To help you make a
decision, you might want to compare PDP and MAPD plan options based on:
- Extent of Coverage
PDP - A stand-alone Medicare Part D prescription drug plan (PDP) covers only out-patient
prescription drugs. A Medicare Part D plan will work together with VA or TRICARE coverage, but will not usually work together with an employer or union healthcare plan that includes drug coverage.
MAPD - A Medicare Advantage plan with drug coverage (MAPD) includes the same Medicare Part D prescription
drug coverage as a PDP - and also includes, at a minimum, the medically-necessary
coverage of Original Medicare Part A (in-patient care) and Medicare Part
B (out-patient and physician care) and sometimes includes limited
dental, hearing, fitness, vision, and other supplemental coverage. As with a PDP, you, most likely, cannot enroll in an MAPD and still keep your employer health plan.
As a note, if you are enrolled in a Medicare Supplement (Medigap policy) and wish to have drug coverage, you can only choose a stand-alone PDP for your drug coverage - you cannot use a Medicare Advantage plan with a Medicare Supplement.
PDP - Stand-alone Medicare Part D plans (PDPs) are simpler than MAPDs - as PDP only provide prescription drug
coverage. When choosing a PDP, you will need to ensure that your medications
are affordably covered on the plan's formulary - and check to see whether the plan has imposed any Usage Management Restriction
on your medications (such as a limit on the quantity you can use in a
month or whether your drugs need prior authorization from the plan
before providing coverage) - and check that your local pharmacies are
included in the prescription drug
plan's pharmacy network (and, depending on your plan, be aware that
some plans use both "preferred" and "standard" pharmacies in their network where preferred network pharmacies may charge you less for formulary drugs than standard network pharmacies).
MAPD - If you choose to enroll an MAPD, you will look at the drug
coverage the same as for a Medicare Part D PDP: Are your drugs
affordably covered? Are there network pharmacies in your area? Are your
local pharmacies preferred or standard network pharmacies - and is there
a cost difference between pharmacies?
However, an MAPD also provides coverage of your Medicare Part A
(hospital and in-patient care) and Medicare Part B (doctor and
out-patient care), so MAPDs provide broader healthcare coverage beyond a
PDP and you need to be prepared to ask questions beyond just drug
If you consider an MAPD you will want to know whether your
preferred physicians or specialists and
are included within the Medicare Advantage plan's healthcare
network. If you rely on a certain group of healthcare
providers, you may find that they are not included in your plan’s
network - and
you will need to have plan approval (pre-authorization) before
visiting a healthcare provider outside of the plan's network - and may
for out-of-network services.
More on the complexity of Medicare Advantage plans:
PDP - A stand-alone drug plan will have a monthly premium (around $10 to over $110),
may have an initial deductible (you pay the first $400- $500 before
your plan begins to pay), and some form of cost-sharing for your drugs
($30 co-pay or 25% of retail drug prices).
MAPD - just like a PDP, you may have an initial deductible and your
plan will have some form of cost-sharing for the formulary drugs,
however, your monthly MAPD premium may be lower than a PDP premium. In
many areas across the country, you can join a $0 premium Medicare
Advantage plan (if available) that includes drug coverage
(MAPD) - and you may find in your area a "give-back"
MAPD that has a $0 premium and actually pays you back a portion of your
Medicare Part B premium. In addition, if you have chronic health
issues, a Medicare Advantage
plan’s Maximum out of Pocket (MOOP) limit may help contain your annual Part A and Part B medical
costs (up to around $8,850 in 2024, depending on the plan).
- Availability and Eligibility
PDP - To enroll into a Medicare Part D prescription drug plan (PDP), you must have either
Medicare Part A and/or Medicare Part B. Remember: Monthly Medicare
Part D premiums are
paid in addition to your Medicare Part A (if any) and/or Part B
premiums. There are no health-related questions when applying for
Medicare Part D
coverage (that is, pre-existing health problems are not considered
You must live in the Medicare Part D plan's Service
Area (usually a single state or a group of states). You can see all Medicare Part D plans in your area by using our PDP Finder: PDP-Finder.com.
MAPD - To enroll into a Medicare Advantage plan, you must have both
Medicare Parts A and B. Remember: Monthly Medicare Advantage plan
premiums (if any) are also paid in addition to your Medicare A and
Medicare Part B premiums.
Like a PDP, there are no health-related questions when applying for a MAPD
(that is, pre-existing health problems are not considered for
enrollment) - except for Medicare Advantage Special Needs Plans
(SNPs)where you must attest to the "Special Need" required by the plan. (The
21st Century Cures Act amended the Social Security Act allowing all
Medicare-eligible individuals with kidney failure/ESRD to enroll in
Medicare Advantage plans beginning January 1, 2021 with the ESRD
question being removed from Medicare Advantage plan enrollment
You must also live in the
Medicare Advantage plan's Service
Area (usually a county, partial county, or ZIP Code region). You
can view all of the Medicare Advantage plans in your area using our
Medicare Advantage Plan Finder (or MA-Finder.com).
Medicare Part D drug plans and Medicare Supplements
Do you only need drug coverage? Do you already have a Medicare Supplement or other Medical insurance?
You cannot use a Medicare Advantage plan with a Medicare Supplement. If
you have healthcare through your employer, you probably do not want to enroll in a PDP or an MAPD (or risk losing your employer coverage).
To enroll into either a stand-alone Medicare Part D PDP or a Medicare Advantage plan, you can use:
- Your IEP - Initial Enrollment Period - the 7-month period surrounding your Medicare eligibility date (such as 65th birthday).
- The AEP - annual Medicare Open Enrollment Period starting each year on October 15th and continuing through December 7th.
- The MA-OEP
- the Medicare Advantage Open Enrollment Period that starts January 1st
and continues through March 31 (only to change or drop a Medicare
Advantage plan, not for changing PDPs).
- an SEP - Special Enrollment Periods - throughout the year you can change
Once you are ready, you can enroll into a Medicare plan many different ways including through an agent, online, through a SHIP, or by calling a Medicare representative at 1-800-633-4227 (1-800-Medicare).
For more information, please see:
- Although we have only discussed MAPDs, Medicare Advantage plans are available in two general varieties: (1) Medicare
Advantage plans with prescription drug coverage (MAPDs) and (2) Medicare
Advantage plans without prescription drug coverage (MAs).
If you want a Medicare Advantage plan and you want Medicare
prescription drug coverage, you will usually need to join an MAPD. In
most cases, you are not able to join an MA and then add a stand-alone
Medicare Part D plan for your prescription drug coverage (unless you
join an MA that is a private-fee for service (PFFS) plan or MSA - with these two types of MAs, you can add a stand-alone Medicare Part D prescription drug plan).
Medicare Advantage plans can be further defined by how the private
insurance carriers choose to implement the Medicare Part A and Medicare
Part B coverage. Some MAPDs/MAs are PPOs (Preferred Provider Organizations) or
HMOs (Health Management Organizations) - and still other MAPDs/MAs are set up
as PFFS (Private Fee for Service Organizations). Medicare Advantage Special Needs Plans (SNPs) are also available and require that you have the condition
or "need" for which the plan is designed (for instance, a specific
chronic condition (like Kidney Failure) or financial status).
"What is the difference between a Medicare Advantage plan and a stand-alone Medicare Part D plan?": Q1FAQ.com/647
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