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Pennsylvania State FlagMedicare Part D Plans in Pennsylvania

Since 1965, Original Medicare has helped seniors pay healthcare costs after they retire. But the program only began covering prescription medications when Congress passed the Medicare Modernization Act of 2003 (MMA). This Act introduced both Part C, more commonly known as Medicare Advantage, and Part D, prescription drug coverage. This page explains Medicare Part D in Pennsylvania.

How Can You Get Medicare Part D in Pennsylvania?

There are two ways to get Medicare Part D in Pennsylvania:

  • A standalone Medicare Part D plan
  • A Medicare Advantage Prescription Drug plan (MA-PD)

Original Medicare includes Part A, hospital insurance, and Part B, medical insurance. Medicare Advantage plans provide the same coverage you get with Original Medicare. However, most MA plans also offer additional benefits, such as prescription drugs, fitness programs, and routine vision and dental care.

A standalone Part D plan works with either Original Medicare or an Advantage plan that does not include prescription drug coverage. (Although around 90 percent of MA plans cover prescriptions, that leaves 10 percent that do not.)

Medicare Advantage Prescription Drug plans are sometimes called all-in-one plans, because they combine your Original Medicare and Part D benefits into a single plan. If you prefer an all-in-one plan, look for the MA-PD designation when comparing prescription drug plan options in Pennsylvania.

You cannot pair a standalone Part D plan with an MA-PD plan.

Who Is Eligible for Medicare Part D in Pennsylvania?

You qualify for Part D as soon as you have Medicare Part A and/or Part B. You must also meet the prescription drug plan's requirements, i.e. living in the plan's service area.

If you are a U.S. citizen or permanent legal resident, you will become eligible for Medicare when you turn 65. Unless you began receiving Social Security benefits at least 4 months before your 65th birthday, however, enrollment in Parts A and B is not automatic. Instead, you must sign up for Medicare via the Social Security Administration.

You can qualify for Medicare before turning 65 if you collect Social Security disability benefits for 24 months. Enrollment in both Parts A and B occurs automatically in your 25th month.

You will never be automatically enrolled in Medicare Part D, even if you already collect Social Security. You must always choose to join a prescription drug plan.

When Can You Enroll in a Prescription Drug Plan in Pennsylvania?

Medicare Part D enrollment in Pennsylvania in limited to specific times.

  • Initial Enrollment Period: Your IEP lasts for a full 7 months. It begins 3 months before the month you become eligible for Medicare. So, if your 65th birthday or 25th month of collecting disability benefits occurs in April, your IEP begins on January 1 and ends on July 31. After you enroll in Part A and/or Part B, you choose a Part D plan.
  • General Enrollment Period: Between January 1 and March 31, those who miss their Initial Enrollment Period AND do not qualify for a Special Enrollment Period (SEP) may apply for Medicare Part A and/or Part B. If you sign up during General Enrollment, you have from April 1 through June 30 to join a prescription drug plan.
  • Medicare Annual Enrollment Period: AEP lasts from October 15 through December 7 and allows current beneficiaries to change their Medicare coverage. This includes signing up for an MA-PD or Part D plan.
  • Medicare Advantage Open Enrollment Period: From January 1 to March 31, Medicare Advantage beneficiaries may either switch to a new MA plan or return to Original Medicare. If the changes you make mean you lose your prescription drug coverage, you may also sign up for a standalone Part D plan during Open Enrollment.
  • Special Enrollment Periods: Certain life changes, like moving to a new address or losing your current coverage, may qualify you for a Special Enrollment Period. Find the full list of qualifying special circumstances on Medicare.gov here.

Comparing Medicare Part D Plans in Pennsylvania

Since private insurance companies provide Medicare Part D plans, coverage and costs may vary widely. You need to review your Pennsylvania prescription drug plan options carefully to ensure you get the best plan for your particular needs and budget.

To begin, make a list of your prescription medications. Then compare your list to the plan's drug formulary, which is the list of medications covered by the plan. A plan that doesn't cover one or more of your prescriptions probably isn't the right plan for you.

This is also a good time to review the plan's drug tiers. This helps you estimate your copay or coinsurance for a particular medication. You pay less for drugs on the lower tiers than you do for ones at the top.

Your out-of-pocket costs for Medicare Part D may include an annual deductible and monthly premium as well as the copays or coinsurnace. Look at all three metrics to determine your full out-of-pocket costs under a particular prescription drug plan.

Medicare beneficiaries who have limited income and resources may qualify for Extra Help. Either Medicare or Social Security should notify you if you qualify for Extra Help in Pennsylvania. You may also contact your plan provider if you think you meet the guidelines for Extra Help.

Nobody from Medicare or Social Security will ever call you unless you specifially request a phone call. All communications are via U.S. mail. If someone calls claiming to be from Medicare or Social Security, hang up and call the appropriate entity (1-800-MEDICARE or 1-800-772-1213).

Do You Have to Have Medicare Part D in Pennsylvania?

No, no part of Medicare is mandatory, including Part D. However, Medicare may charge you a late enrollment penalty if you delay signing up AND do not have creditable coverage elsewhere. You face lifelong late penalties if you go 63 days or more without Part D coverage. (A creditable prescription drug plan is comparable to Medicare Part D in terms of price and coverage.)

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