Medicare Advantage Prescription Drug Plans (MAPD)

Most Medicare beneficiaries have the option to enroll in a Medicare Advantage Prescription Drug (MAPD) plan as an alternative to their Medicare Part A and Part B (Original Medicare) benefits.

Original Medicare covers numerous hospital and medical costs but generally does not include prescription drug coverage.

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What do MAPD plans cover?

All MAPD plans must provide at least the same hospital and medical benefits as Original Medicare and provide coverage for prescription drugs.

Some MAPD plans also offer additional benefits not offered by Original Medicare such as dental, vision and hearing coverage.

How do MAPD plans work?

MAPD plans are sold and managed by private insurers, so each plan can vary in cost and drugs covered.

How your MAPD plan works in terms of provider networks, costs and coverage will depend on the type of Medicare Advantage plan you’re enrolled in.

Medicare Preferred Provider Organization (PPO) plans

If you’re enrolled in a Medicare PPO plan, you usually pay less if you stay within a network of certain providers and pharmacies that have partnered with your PPO plan. If you visit a provider or pharmacist outside of the plan network, you may pay higher out-of-pocket costs.

Some local PPOs feature a smaller network limited to the county or state, and some regional PPOs have networks that may encompass several states.

Medicare Health Maintenance Organization (HMO) plans

With a Medicare HMO plan, you must stay within your plan’s network of providers or pharmacies. If you go outside of your plan’s network, your MA plan will not cover the costs of your care, and you are responsible for 100 percent of the costs (except for cases of emergencies and out-of-network dialysis services).

Medicare Private Fee For Service (PFFS) plans

Medicare PFFS plans permit you to go to any provider in the U.S. who accepts Medicare. Some PFFS plans have a network of contracted providers. If your PFFS plan has a network, you will typically pay less out of pocket for medical care and services if you stay within your plan’s network.

Medicare Medical Savings Account (MSA) plans

Medicare MSA plans do not cover prescription drugs and are not MAPD plans. If you have an MSA plan, you can enroll in a Medicare Part D plan to help cover the cost of prescription drugs.

These high-deductible Medicare plans deposit money into a health savings account, which you can use to pay for health care services before you meet your deductible. Once your deductible is met, you pay a percentage of covered services and drugs, and your Medicare plan pays the rest.

What is a Medicare drug formulary?

Each Medicare Advantage Prescription Drug plan has its own drug formulary, which is a list of brand-name and generic drugs that the plan covers.

Drugs are typically organized into tiers, with drugs in higher tiers costing more than drugs in lower tiers. Your insurer can tell you which of your prescription drugs are covered by an MAPD plan.

What is the Medicare donut hole?

Some Medicare Advantage Prescription Drug Plans have what is known as a “donut hole” or “coverage gap,” which is a temporary limit on how much the drug plan will pay for prescription drug costs.

Generally, once you and your drug plan spend more than $3,820 (in 2019) in a single year on prescription drugs, you enter the coverage gap. While you are in the coverage gap, you are responsible for paying a larger portion for covered drugs until you reach $5,100.

Once you’ve spent $5,100 on prescription drugs in 2019, you will leave the donut hole and enter catastrophic coverage. While in the catastrophic coverage phase, you only pay a small coinsurance or copayment for covered drugs for the remainder of the year.

Find MAPD plans in your area

A licensed insurance agent can help you find Medicare Advantage Prescription Drug Plans in your area and help you enroll in a plan that works for you.

Speak with a licensed agent by calling TTY Users: 711 24 hours a day, 7 days a week.

When you speak with an agent, you can compare plans from a number of different insurance providers. Some of the MAPD plan options that may be available to you can include:

Not all plans are offered in all locations, and some carriers may not provide an MAPD plan where you live. A licensed agent can help you review the availability, costs and benefits of Medicare plans in your area.

Copyright 2018 TZ Insurance Solutions LLC. All rights reserved.

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts; enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, 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 has neither reviewed nor endorsed this information.