Medicare Part D FAQ

Here are some of the most frequently asked questions about Medicare Part D and drug formularies. If your question is not included, please send us an email and we will get back to you as quickly as possible.

  1. Who can get Medicare Part D prescription drug coverage?
  2. Do I have to enroll in Medicare Part D?
  3. Can I get Medicare Part D prescription drug coverage if I don’t have a Medicare supplement or Medicare Advantage plan?
  4. If I am turning 65 and want Medicare Part D drug benefits, can I join a Medicare Prescription Drug Plan or Medicare Advantage plan only at certain times of the year?
  5. I’m currently enrolled in a Medicare supplement plan with prescription drug coverage. Do I have to change plans if I want to keep my prescription drug coverage?
  6. If I am currently enrolled in a Medicare supplement plan that includes prescription drug coverage and want to enroll in a Medicare Part D plan, can I?
  7. What is the Medicare Part D formulary?
  8. How will my doctor know to prescribe a medication on the formulary?
  9. What is the mail order program for Medicare Part D?
  10. What is the coverage gap (donut hole) phase of coverage?
  11. What are the prescription drug costs in the coverage gap?
  12. What payments count towards your out-of-pocket costs?

1. Who can get Medicare Part D prescription drug coverage?
All Medicare beneficiaries are eligible to enroll. You must be entitled to Medicare Part A or enrolled in Medicare Part B. You must also live in the service area of the plan you join. Our service area includes Bucks, Chester, Delaware, Montgomery, and Philadelphia counties. For Keystone 65 HMO, you must be a resident of Bucks, Chester, Delaware, Montgomery or Philadelphia counties in Pennsylvania. For Personal Choice 65 PPO, you must be a resident of Bucks or Philadelphia counties in Pennsylvania.

2. Do I have to enroll in Medicare Part D?
No. Enrollment in Medicare Part D is voluntary. However if you don’t enroll in a Part D plan as soon as you’re eligible, you may pay a penalty if you enroll later.

3. Can I get Medicare Part D prescription drug coverage if I don’t have a Medicare supplement or Medicare Advantage plan?
Yes. If you are enrolled in Original Medicare, you can continue with it and choose your Part D coverage from a private plan that provides coverage only for prescription drugs.

4. If I am turning 65 and want Medicare Part D drug benefits, can I join a Medicare Prescription Drug Plan or Medicare Advantage plan at any time?
No. If you are turning 65, you may enroll in a Medicare Prescription Drug Plan or Medicare Advantage plan during your Initial Coverage Election Period for Medicare Part B. This period includes the three months prior to your birth month, your birth month, and the three months after your birth month.

5. I’m currently enrolled in a Medicare supplement plan with prescription drug coverage. Do I have to change plans if I want to keep my prescription drug coverage?
No. As long as you are enrolled in a Medicare supplement plan that provides prescription drugs prior to January 1, 2006, you can remain in this Medicare supplement plan. However, if you decide to enroll in a Medicare Part D drug plan later, you may pay a penalty for late enrollment.

6. If I am currently enrolled in a Medicare supplement plan that includes prescription drug coverage and want to enroll in a Medicare Part D plan, can I?
Yes. You can move to a medical-only Medicare supplement plan and join a standalone Part D drug plan.

7. What is the Medicare Part D formulary?
A formulary is a defined list of medications that have been selected for their medical effectiveness, positive results, and value. When you have your prescription filled at a participating network pharmacy, you will have lower out-of-pocket costs when you use a drug on the formulary. If a drug is not on the formulary, your out-of-pocket costs will be higher. A mail order pharmacy is also available.

8. How will my doctor know to prescribe a medication on the formulary?
Have your doctor review the Drug Formulary Pocket Guide to determine if your prescription medications are on the formulary. You might already be taking formulary medications. If you are, you will pay only your cost-share for these drugs. If you are prescribed covered drugs that are not on the formulary, ask your doctor to review your Drug Formulary Pocket Guide to see if another drug on the formulary, such as a generic equivalent or therapeutic alternative, can be used to treat your condition. If, after discussion with your doctor, he/she does not prescribe a formulary medication, your covered prescription will be subject to the higher cost-share.

9. What is the mail order program for Medicare Part D?
The voluntary mail order program saves you copays and allows you to get medications delivered directly to your home. When you are prescribed a maintenance drug, ask your doctor to write you two prescriptions — one for a 31-day supply to be filled immediately at a local, participating pharmacy and one for a 90-day supply (plus any necessary refills) to be filled through mail order. Once you are enrolled, you will receive a mail order envelope in your Welcome Kit. You may obtain additional mail order envelopes by calling the number on the back of your identification card or contact us.

10. What is the coverage gap (donut hole) phase of coverage?
Most Medicare Part D plans have a coverage gap. The coverage gap begins after you (or others on your behalf) and your drug plan have spent a certain amount for covered drugs, called the Initial Coverage Limit. Once you reach the Initial Coverage Limit, your cost-sharing for Part D drugs may increase (see below for more information). Please note that not everyone will have increased cost-sharing in the coverage gap. People with Medicare who get Extra Help paying Part D costs will not have increased cost-sharing in the coverage gap for covered Part D drugs.

11. What are the prescription drug costs in the coverage gap?
In 2013, you enter the coverage gap once your total drug spend (combination of deductible, cost-sharing, and plan payments) exceeds the Initial Coverage Limit of $2,970 and ends when your True Out-of-Pocket (TrOOP) costs reach $4,750.

Once you enter the coverage gap, you are now responsible for paying for 47.5% of the price of brand-name drugs. Although you’ll only pay 47.5% of the cost for the brand-name drug, the entire cost of the drug will count as out-of-pocket spending, which will help you get out of the coverage gap. You’ll also pay only 79% of the cost for covered generic drugs until you reach the end of the coverage gap.

12. What payments count towards your out-of-pocket costs?
Your yearly out-of-pocket costs, which include your deductible (if applicable), coinsurance, and copayments paid for covered Part D drugs, as well as the full cost of brand-name drugs paid for during the coverage gap count towards your out-of-pocket costs. Your drug plan premium and non-covered drugs do not count towards your out-of-pocket costs.

Website last updated: 9/30/2012
Y0041_HM_13_3639 Approved 11/09/12