What is the Medicare prescription drug program and how do I enroll?

The Medicare prescription drug program, which is often referred to as Medicare Part D, began on January 1, 2006. The Part D program is different from Part A and Part B because Part D Medicare contracts with private companies to provide the drug coverage. There is no coverage available directly through Medicare itself. Part D covers both brand name and generic prescription drugs at participating pharmacies.  

The prescription drug program is similar to other types of insurance and is optional for Medicare beneficiaries. Though there are minimum standards required by Medicare, each plan has different premiums, deductibles, co-payments, and some plans do not cover certain medications. Because there are so many plans and so many variables to consider, the easiest way to compare plans is through Medicare’s Plan Finder Website at http://www.medicare.gov. You can access the site yourself, have someone access the site on your behalf, contact the SHIP counselor at your local senior center to assist you, or call our state Part D hotline at 1 (877) 987-4463 or Medicare at 1 (800) 633-4227. 

Important considerations for choosing a plan include whether the drugs you currently take are on the plan’s formulary, what the out-of-pocket costs are to you, whether your preferred pharmacy will accept the plan, and what the accessibility and quality of customer service is for the plan.  

You may be able to get extra help in paying your out-of-pocket costs for a plan if you are low-income and have limited assets. You can apply for this extra help by calling Social Security at 1 (800) 772-1213 or by visiting http://www.ssa.gov. (See also the question about Extra Help on page 41.) 

Any West Virginian with Medicare Part A and/or Part B may choose to join a Medicare prescription drug plan. Most people become eligible when they enroll in Medicare. The initial enrollment period lasts six months, and it begins three months before you get Medicare. There is also an open enrollment period every year from October 15 through December 7. If you were eligible when the program began your initial enrollment period was November 15, 2005 to May 15, 2006. If you missed your initial enrollment period, you may be subject to late enrollment penalties. The penalty amount changes every year, and you will have to pay it as long as you have Medicare prescription drug coverage. To calculate your penalty amount estimate, multiply 1% of the national base beneficiary premium ($33.13 × 1% = .33 in 2015) by the number of months you were eligible to join a medicare drug plan but didn’t. Then, round this number to the nearest ten cents. As mentioned previously, this amount is added to your Medicare drug plan’s premium each month for as long as you have the plan. 

If you already have prescription coverage, such as a plan from an employer or union, you can likely keep that coverage. A prescription plan that offers benefits that are the same as or better than a Medicare prescription plan is called a creditable coverage plan. If your employer or union plan is creditable coverage, you will not be penalized with a higher premium if you decide to join a Medicare plan later. You also may drop your employer or union coverage and enroll in a Medicare approved plan. However, it is important to note that once you drop employer or union coverage, you may be unable to get that coverage back. If your employer or union plan covers less than a Medicare prescription drug plan, you can keep your current drug plan and also join a Medicare prescription drug plan to obtain more complete coverage. Your current insurer can tell you if you have creditable coverage right now. SHIP counselors are available to assist with questions and problems related to Medicare Part D including enrollment, penalties, coverage, and more. 

For more information, see: Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2015), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015).