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Medicare Prescription Drug Coverage Guide

Part 5: Choosing a Part D Drug Plan

How to find the one that's right for you

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How do I compare “stand-alone” drug plans with Medicare Advantage (MA) plans?

The critical question is what kind of medical services you want. These are points to consider:

  • Traditional Medicare doesn’t include drugs, so you’d also need to join a separate stand-alone plan (which covers only drugs) to get drug coverage.

  • Most MA plans offer medical and drug coverage as a comprehensive package, but not all plans cover drugs.

  • Joining an MA plan means receiving your Medicare health benefits through the plan and accepting its terms and conditions.

  • Most MA plans are HMOs or PPOs, which require you to go to the doctors and hospitals in its regional network or pay more to go out of network. (Two other types of MA plans, known as Private Fee for Service and Medicare Medical Savings Accounts, which are not available everywhere, have different arrangements.) Traditional Medicare allows you to see any health providers that accept Medicare patients, anywhere in the country.

  • You cannot be in a stand-alone drug plan at the same time as being enrolled in an HMO or PPO type of Medicare Advantage plan, even if the MA plan does not include drug coverage. However, if you join a Private Fee-for-Service health plan or a Medicare Medical Savings Account plan that doesn’t offer prescription drugs, you can enroll in a stand-alone plan to add drug coverage.

  • If you’re already in a stand-alone drug plan and join an MA plan that provides drug coverage, be aware that your enrollment in the stand-alone plan will be automatically canceled.

  • If you’re already in an MA plan, be aware that joining a stand-alone drug plan will automatically cancel your MA plan coverage and re-enroll you in the traditional Medicare program.

  • If you have health coverage from a former or current employer or union, joining an MA plan could automatically cancel your present coverage. Make sure you know the consequences to your (and your dependents’) health coverage before joining an MA plan.

So deciding first how you prefer to have your medical care delivered will considerably narrow your choices. You can compare MA plans at the Medicare website. Enter your ZIP code and follow the instructions.

What if I can’t find a plan that covers all my drugs?

Find a plan that covers most of your drugs, especially expensive ones. Then talk to your doctor to see if any of the others can be switched to similar drugs that are covered by the plan. Also, your specific medical condition may qualify you for an exception that pays for a drug not on the plan’s formulary. Once you’ve joined a plan, you can appeal for an exception with your doctor’s support. For details, see Part 1 of this guide.

What else is important to look at when comparing plans, besides coverage, premiums, and copays?

A plan may cover your drugs, but it’s also important to find out whether any of them come with restrictions. This means that the plan won’t cover specified drugs until you’ve met certain conditions. These restrictions — Prior Authorization, Step Therapy, or Quantity Limits — and how you may be able to get them waived are explained in Part 1 of this guide.

Remember: Although all Part D plans impose restrictions on some drugs, they don’t all restrict the same drugs. Before enrolling use the Medicare plan finder or call Medicare or call your chosen plan itself to find out what, if any, restrictions it places on your drugs.

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