The prescription drug plans available in Illinois are announced prior to the annual enrollment period between October 15 and December 31. The overall value of the drug coverage offered by each Plan must be the same or greater than the Standard Plan outlined in the Medicare law.
However, plans can vary in what drugs they cover, the co-payments you must pay, and a variety of other limitations, including what pharmacies they will let you use.
There are 2 ways you can get your Medicare drug coverage:
Stand-alone prescription drug plans (PDP)
These plans offer Part D drug coverage only.
Medicare Advantage Prescription Drug Plans (MA-PD)
These are health plans offered by private companies that provide Medicare Part A and Part B services as well as the Part D drug benefit.
Most MA plans sold in Illinois are by health-maintenance organizations (HMO), preferred-provider organizations (PPO) or private fee-for-service (PFFS) plans. PFFS policies allow the user to go to any medical provider who agrees to its payment terms, but PPO and HMO plans require you to use their own network of medical professionals. You can go outside the network with a PPO plan, but you will pay higher costs.
If you are currently enrolled in a MA-PD that has a drug benefit, you must receive your prescriptions through your Medicare Advantage Prescription Drug Plan (MA-PD) instead of a PDP. However, if your plan does not include a prescription drug option, you may enroll in a PDP.
If you wish to enroll in a MA-PD, you must:
- Be eligible for Medicare
- Be enrolled in both Medicare Part A and Medicare Part B (you can check this by referring to your Red, White, and Blue Medicare Card)
- Live within the plan’s service area (which is county-by-county; not state-by-state), and
- Not have End-Stage Renal Disease (or ERD)
Private companies offer different plans you can choose from. They provide different benefits for different costs. It is important that you shop for the right plan using the factors explained below.
There are many sources for help in this process, including the Senior Health Insurance Program (SHIP), 1-800-548-9034 or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Choosing the right plan
In order to choose a plan that works best for you, you will need to look carefully at the costs and other requirements for each plan, and compare the drugs covered in each plan to your own medication needs.
Some of the factors to consider when choosing a prescription drug plan include:
- The monthly premiums and the annual deductible, if any
- The amount of the co-payments (the set amount you pay for drugs may be different for each tier level)
- Whether the plan formulary includes the drugs you need, at the strengths and dosages you need
- Whether the plan offers coverage during the coverage gap and whether such coverage is for generic drugs only or both generic and brand drugs
Some important considerations are the following:
- Whether the plan’s network includes the pharmacies you use
- Whether mail order is allowed or required
- Whether the plan requires prior authorization before obtaining certain drugs or requires that you try particular drugs before those prescribed by your doctor
- Whether there are limitations on the number of prescriptions in a month or number of pills in a prescription
- Whether the plan offers supplemental benefits that are important to you
All plans offer coverage until you hit a limit of $3,310 in total drug costs, and all plans offer coverage when your out-of-pocket costs exceed $4,850. But only some plans offer coverage during the gap between $3,310 in total costs and $4,850 in out-of-pocket costs.