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How will I choose between a stand-alone Medicare Part D prescription drug plan (PDP) and a Medicare Advantage plan that includes prescription drug coverage (MAPD)?



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Question: How will I choose between a stand-alone Medicare Part D prescription drug plan (PDP) and a Medicare Advantage plan that includes prescription drug coverage (MAPD)?
Category: Medicare Advantage Plans (MAPD)

Answer: Medicare prescription drug coverage is available through either stand-alone Medicare Part D prescription drug plans (PDPs) or Medicare Advantage plans that include prescription drug coverage (MAPDs).

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 these two types of Medicare plan options based on:
  • Coverage - 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 into a PDP or an MAPD (or risk losing your employer coverage).

  • Complexity - If you choose an MAPD, ask whether your drugs, pharmacies, doctors, specialists, hospitals all included within the plan’s coverage or 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 approval to go outside of the plan's network - and may pay more for out-of-network services.
  • Availability - Is there a Medicare Advantage plan available in your Service Area (most Medicare Advantage plans are found in population-dense areas)?   Is a PDP the only drug plan alternative available for you?  Do you have ESRD (kidney failure) that would keep you from enrolling in a MAPD?

  • Cost - Are you healthy and looking to avoid the late-enrollment premium penalty?  If so, you may wish to just join a $0 premium Medicare Advantage plan (if available) that includes drug coverage (MAPD).   If you are unhealthy or have chronic health issues, a Medicare Advantage plan’s Maximum out of Pocket (MOOP) limit may help contain your annual medical costs (albeit to around $6,700, depending on the plan).
More on Coverage:
  • A stand-alone Medicare Part D 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 employer healthcare plans.

  • A Medicare Advantage plan (MAPD) includes the same Medicare Part D prescription drug coverage as a PDP - and 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, and vision coverage - plus Medicare Advantage plans may include fitness coverage such as the Silver Sneakers program.  As mentioned, you cannot use a Medicare Advantage plan with a Medicare Supplement.  You probably cannot enroll in an MAPD and still keep your employer heath plan.
More on Complexity:
  • Stand-alone Medicare Part D plans (PDPs) only offer prescription drug coverage and plan members need to ensure that their medications are covered in the plan formulary and local pharmacies are included in a prescription drug plan network (and be aware that preferred network pharmacies will charge less than non-preferred network pharmacies).

  • Medicare Advantage plans are available in two general varieties: Medicare Advantage plans with prescription drug coverage (MAPDs) and Medicare Advantage plans without prescription drug coverage (MAs).

    Naturally, a Medicare Advantage plan (MAPD or MA) is much more complicated than a Medicare Part D plan. In a Medicare Advantage plan that includes prescriptions (MAPD), the plan member must also ensure that their prescriptions are covered at their local pharmacies (preferred or non-preferred network pharmacies) - plus MAPD plan members must determine whether their favorite physicians or specialists and hospitals are included or excluded from the Medicare Advantage plan network.  An MAPDs has the right to change the plan's healthcare provider network throughout the plan year dropping primary care physicians (PCPs) and specialists.

    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).

    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 MAs are PPOs (Preferred Provider Organizations) or HMOs (Health Management Organizations) - and still other MAs are set up as PFFS (Private Fee for Service Organizations).  Medicare Advantage Special Needs Plans (SNPs) require that you must have the condition or "need" for which the plan is designed (for instance, a specific chronic condition (like Kidney Failure) or financial status).
More on Availability:
  • To enroll into a Medicare Part D prescription drug plan, you must have either Medicare Part A and/or Medicare Part B. Medicare Part D premiums are 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 for enrollment).

    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.

  • To enroll into a Medicare Advantage plan, you must have both Medicare Parts A and B . The Medicare Advantage Plans are operated by private insurance carrier and compensated by the federal government. Medicare Advantage premiums are also in addition to your Medicare A and Medicare Part B premiums.

    The only health-related question asked when applying for a Medicare Advantage plan is whether you suffer from End-Stage Renal Disease (ESRD or Kidney Failure) - plus if you join a Medicare Advantage Special Needs Plan (SNP), you must have the condition or "need" for which the plan is designed.  Other pre-existing health problems are not considered for enrollment into a Medicare Advantage plan.

    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).
More on Cost:
  • Medicare Part D plans charge a monthly premium that ranges from around $10 to well over $100.  Members will pay a cost-sharing rate for their medications (co-payment or co-insurance) until reaching a certain level (the Initial Coverage Limit), then enter the Donut Hole or Coverage Gap, receive the Donut Hole Discount, and members can ultimately spend their way into Catastrophic Coverage (if your 2019 monthly retail drug costs are over $318) when plan members will pay about 5% for their medications for the remainder of the year.

  • Medicare Advantage plans with drug coverage (MAPDs) can range in premiums from $0 to hundreds of dollars.  Some Medicare Advantage plans not only have a $0 premium, but you actually get a portion of your Medicare Part B premium "rebated" or payed-back to you.

    Medicare Part D prescription drug coverage provided by a Medicare Advantage plan follows the same Medicare Part D drug plan phases as described above, but may offer lower plan limits: Members will pay a cost-sharing rate for their medications until reaching a certain level, then enter the Donut Hole or Coverage Gap, receive the Donut Hole Discount, and can ultimately spend their way into Catastrophic Coverage where plan members will pay a maximum of around 5% for their medications for the remainder of the year.

    One of the biggest benefits of a Medicare Advantage plan is that there is a limit to your out-of pocket medical spending each year .  If you have Original Medicare Part A and Medicare Part B, there is no limit or cap to what you can pay each year, if you have very high medical expenses, you could have very high costs.  However, with your Maximum out-of-pocket limit (or MOOP), your private Medicare Advantage plan will limit your potential medicare spending each year to some level such as $3,400, $5,000, or $6,700 - depending on your chosen plan.
For more information, please see:
"What is the difference between a Medicare Advantage plan and a stand-alone Medicare Part D plan?":  https://Q1News.com/35.html

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.