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MAPD vs. PDP Through Medicare Part D


When choosing your Medicare coverage, you have several options to cover your health needs and fit your budget. Original Medicare is the basis of your healthcare coverage.

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However, this insurance you receive through the government does not pay for prescription drugs. To receive these benefits, you must decide between Medicare Advantage Prescription Drug (MAPD) and Medicare Part D plans.

Below, we explore why an MAPD or Medicare Part D plan is essential when you have Medicare.

What is the Difference Between MAPD and PDP Plans?

Original Medicare is made up of Medicare Part A, which covers hospital care, and Part B, which covers outpatient services. Private insurance companies offer Medicare Part C (Advantage) and Part D policies to help pay for prescription drugs. Further, Medicare Advantage plans come with additional benefits – but often some caveats.

When you enroll in a Medicare Advantage plan with an MAPD component, you receive the coverage that Original Medicare provides, plus prescription drug and other benefits bundled into one policy. When you have MAPD coverage, your insurance carrier handles your claims instead of Medicare. Thus, it becomes your primary insurance instead of Original Medicare.

In contrast, Medicare Part D prescription drug plans (PDP) are stand-alone plans that only provide prescription drug coverage through Medicare Part D. You can purchase a Medicare Part D PDP if you keep your Original Medicare, with or without a Medicare Supplement plan.

By law, each Medicare Part D PDP must offer standard benefits per Medicare, covering certain drugs under its formulary. However, like MAPD coverage, Medicare Part D prescription drug plans vary by location and provider.

Additionally, you cannot enroll in MAPD and Medicare Part D PDP plans simultaneously. You may only enroll in one type of drug coverage at a time, so it is vital to choose wisely.

What Types of MAPD and Medicare Part D Plans are Available?

Several Medicare Advantage plan types that include MAPD coverage are available. The plan you choose dictates your healthcare coverage as well as your drug coverage.

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Also, these policies may possess additional benefits that Original Medicare does not typically include. So, ensuring that your Medicare Advantage plan holistically fits your needs is crucial – not just through the PDP.

Not all locations offer the same types of Medicare Advantage plans with MAPD coverage. The most common types include Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO).

HMOs are most common in the Medicare Advantage world, but they are the most restrictive, with potentially limiting provider networks. Additionally, those on HMOs may need a referral before seeing a specialist.

On the other hand, PPOs have less restrictive doctor networks. Yet, they come with higher premiums than HMO plans.

Two additional types of Medicare Advantage plans offering MAPD coverage are Private Fee-for-Service (PFFS) and Special Needs Plans (SNP). Only people with specific health conditions and special financial needs can enroll in an SNP.

Finally, PFFS plans do not have networks so you can see any doctor of your choice – if they accept the payment terms. A PFFS plan may also lack drug coverage. So if you have a Medicare Advantage PFFS plan, you can pick up a PDP through Medicare Part D.

Several Medicare Part D PDP plans are available through multiple carriers. Unlike the different types of coverage that comes along with MAPD benefits, the basis of all Medicare Part D PDPs is the same.

Each Medicare Part D plan comes with a pharmacy network. When using a Medicare Part D PDP, be sure to use a preferred pharmacy and that the plan’s formulary covers your drugs.

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Who is Eligible for MAPD vs. Part D?

If you are eligible for Original Medicare, you also qualify for MAPD or PDP coverage through Medicare Part D. You can enroll in either coverage if you:

  • Are a U.S. citizen
  • Have either or both Medicare Part A and Part B
  • Live in the service area of your desired plan

When you first become eligible for Original Medicare, you can enroll in a Medicare Advantage plan with an MAPD benefit or keep your Original Medicare and enroll in a Medicare Part D PDP. However, you cannot do both.

When Can I Enroll in an MAPD or Medicare Part D?

Your first chance to pick up prescription drug coverage is when you enroll in Original Medicare. You can enroll in drug coverage up to three months before your Original Medicare effective date, the month of, and three months following your 65th birthday.

After your initial Medicare enrollment, you have opportunities to make changes to your coverage each year.

  • Medicare Advantage Open Enrollment Period – This window is only for those with Medicare Advantage plans.  If you are unhappy with your MAPD benefits – or any other aspects of your Medicare Advantage plan – you can make one change between January 1 and March 31 each year. After you drop a Medicare Advantage plan, you can also pick up a Medicare Part D PDP. Then, your change goes into effect on the first day of the following month.
  • Initial Coverage Election Period – If you enroll in Medicare Part B during the General Enrollment Period (January 1 to March 31), you can enroll in an MAPD or Medicare Part D PDP from April 1 through June 30. When you enroll at this time, coverage goes into effect on July 1.  
  • Annual Enrollment Period – Each year, between October 15 and December 7, you get an opportunity to review your MAPD or Medicare Part D plan’s changes for the new year and make changes. The latest change you make goes into effect on January 1.

How Much Do MAPD vs. Part D Plans Cost?

When you enroll in an MAPD or Medicare Part D plan, you will need to understand your out-of-pocket costs for prescription drugs. Depending on the plan you select, you may be responsible for:

  • A monthly premium
  • Copayments
  • Coinsurance
  • Deductibles

Additionally, most plans have a maximum-out-of-pocket limit for the year. So if you meet this benchmark amount, your MAPD or PDP plan will cover 100% of your remaining costs.

Your carrier and area of residence will determine the actual cost. Unlike with Medicare Supplement plans, your health will never be a factor in determining the cost of MAPD or PDP coverage. Also, remember that with either type of plan, you will still need to pay your Medicare Part B premium.

Is It Better to Have MAPD or PDP Coverage?

There is no one-size-fits-all coverage, as everyone has different needs. With a large selection of options, your answer depends on your health and budget.

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As you shop around, keep your answers to these questions in mind:

  1. Do I plan on traveling within the next year?
  2. Can I still afford my current prescription drug coverage?
  3. Have my medical needs changed?
  4. Did I have any issues with my current plan in the last year?
  5. Are my medications and dosages still on my plan’s formulary?

Those who travel often may not wish to be subject to the restrictions of Medicare Advantage networks and so choose a Part D plan instead. On the other hand, those who want an all-in-one plan may prefer MAPD coverage.

Each drug plan involves a formulary that may change each year. Before purchasing prescription drug coverage, double-check to ensure the formulary includes your medications and dosages. Once you find plans that cover your medications, you can compare them and determine your best course of action.

FAQs

Can you have a PDP and an MAPD?
You cannot have both a PDP through Medicare Part D and an MAPD simultaneously. However, it is not a concern because you will not need both; your MAPD is your drug coverage through Medicare Advantage, as almost all Part C plans include MAPD. You may, however, add Medicare Part D coverage to your Advantage plan if it is a Private Fee for Service (PFFS) or Medical Savings Account plan without drug coverage.
Is a PDP a Medicare Advantage plan?
The short answer is no. Medicare prescription drug plans (PDPs) are commonly known as Part D; Medicare Advantage plans include Medicare Advantage Prescription Drug plans (MAPD). PDPs are sold through private insurance companies, like Medicare Advantage plans.
Does the donut hole apply to MAPD plans?
Yes, MAPD plans involve the same type of donut hole as PDP plans through Medicare Part D. Your MAPD will come with limitations on what prescription drugs it covers.
Do MAPD costs count toward my Advantage plan’s maximum out-of-pocket?

How to Decide Between MAPD vs. Medicare Part D Coverage

When it comes to prescription drug coverage, no two people have identical needs. So, what may be best for one person may not be right for another. We recommend exploring all your options, understanding the plan benefits, and reviewing formularies before selecting a policy.

To compare all the highest-rated plans available in your area, call the number above to speak with an agent today. We can help! If you cannot call now, complete our online form to compare rates. You will receive a side-by-side comparison of your best drug plan options.

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Sources:

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Drug coverage (Part D), Medicare. Accessed June 2022.
    https://www.medicare.gov/drug-coverage-part-d
  2. What Medicare Part D drug plans cover, Medicare. Accessed June 2022.
    https://www.medicare.gov/drug-coverage-part-d/what-medicare-part-d-drug-plans-cover
  3. Your Guide to Medicare Prescription Drug Coverage, Medicare. Accessed June 2022.
    https://www.medicare.gov/sites/default/files/2021-07/11109-Medicare-Drug-Coverage-Guide_0.pdf
  4. How do Medicare Advantage Plans work?, Medicare. Accessed June 2022.
    https://www.medicare.gov/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work

Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

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