Question: Is there really any difference between a Medicare Part D Prescription Drug plan and a Medicare Advantage plan?
Answer: Yes! A stand-alone Medicare Part D plan (PDP) cover only out-patient prescription drugs. A Medicare Advantage plan can include prescription drug coverage 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 the plan may include fitness coverage such as the Silver Sneakers program.
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 (MA).
Naturally, a Medicare Advantage plan (MAPD or MA) is much more complicated than a Medicare Part D plan.
In a stand-alone PDP, plan members need to ensure that their medications are covered and local pharmacies are included in a prescription drug plan network.
In a Medicare Advantage plan that includes prescriptions (MAPD), the plan member must ensure that their prescriptions are covered at their local pharmacies and they must determine whether their favorite physicians or specialists and hospitals are included or excluded from the Medicare Advantage plan.
As noted, a Medicare Advantage plans combines your Medicare A (hospitalization) and Medicare B (medical, like Doctor visits) - plus usually some additional benefits like vision or dental. If you have a MAPD, then your Medicare Advantage plan also covers prescription drug coverage or Medicare Part D.
Requirements for Enrollment 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 also live in the Medicare Part D plan's Service Area (usually a single state or a group of states).
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. Some Medicare Advantage plans do not charge much of a premium (or a $0 monthly premium) - 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. As mentioned, Medicare Advantage Plans often provide the additional prescription drug coverage (MA-PD) at a reduced or no cost. 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 (for instance, a specific chronic condition (like Kidney Failure) or financial status). 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).
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 PPO (Preferred Provider Organizations) or HMOs (Health Management Organizations) - and still other MAs are set up as PFFS (Private Fee for Service Organizations).
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.
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
Beneficiaries can appoint a representative by submitting CMS Form-1696.