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MAPD vs. PDP Through Medicare Part D


Original Medicare does not offer prescription drug coverage. This means you must enroll in separate drug coverage to receive benefits. When choosing your coverage, you have several options to cover your health needs and fit your budget. Prescription drug coverage through Medicare typically comes in the form of a Medicare Part D plan or a Medicare Advantage Prescription Drug Plan (MAPD).

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Below, we explore why an MAPD or Medicare Part D plan is essential when you have Medicare and help you determine which option may be best for you.

What is a Medicare Advantage Prescription Drug Plan?

Original Medicare consists of Medicare Part A, which covers hospital care, and Part B, which covers outpatient services. Private insurance companies offer Medicare Part C (Medicare Advantage) and Part policies to help pay for prescription drugs.

A Medicare Advantage plan that includes prescription drug coverage is often called a MAPD plan. MAPD plans combine Original Medicare benefits plus additional benefits that may not typically be covered by Medicare, such as dental, vision, and hearing coverage. However, MAPD plans may also have caveats, such as high out-of-pocket costs and restrictive networks.

Therefore, it is essential to understand your plan’s benefits to ensure the coverage you enroll in best fits your budget and healthcare needs.  

What is the Difference Between MAPD and Medicare Part D Plans?

When you enroll in MAPD coverage, your insurance carrier handles your claims instead of Medicare. Thus, it becomes your primary insurance rather than Original Medicare.

On the other hand, Medicare Part D prescription drug plans (PDP) are stand-alone plans that only provide prescription drug coverage through Medicare Part D. Thus, your claims will still be handled by Original Medicare if you purchase a Medicare Part D plan.

By law, each Medicare Part D Prescription Drug plan 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 simultaneously enroll in MAPD and Medicare Part D Prescription Drug plan plans. You may only enroll in one type of drug coverage at a time, so it is vital to compare your options and choose wisely.

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What Types of MAPD Plans are Available?

Several types of Medicare Advantage plans include MAPD coverage. It is essential to choose the best plan type for your needs, as the plan you choose dictates your healthcare coverage and your drug coverage.

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 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 the most common Medicare Advantage plan type, but they are also the most restrictive, with potentially limiting provider networks and high out-of-pocket costs. Additionally, those on HMO plans may need a referral before seeing a specialist.

On the other hand, PPO plans have less restrictive doctor networks and more freedom when it comes to choosing your healthcare. Yet, they often come with higher premiums than HMO plans.

Two additional and less common types of Medicare Advantage plans to offer MAPD coverage are Private Fee-for-Service (PFFS) and Special Needs Plans (SNP) – only people with specific health conditions and unique financial needs can enroll in an SNP.

PFFS plans do not have networks, so you can see any doctor who accepts Original Medicare. However, these plans are the least likely to include drug coverage. Therefore, if you have a Medicare Advantage PFFS plan without prescription coverage, you can pick up a prescription drug plan through Medicare Part D.

What Types of PDP Plans are Available?

Several Medicare Part D Prescription Drug plans are available through multiple carriers nationwide. Unlike the different types of coverage that come with MAPD benefits, the basis of all Medicare Part D Prescription Drug plans are the same.

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

There is no one-plan-fits-all option for Medicare Part D. You must enroll in the plan that best covers your prescribed drugs.

Who is Eligible for MAPD vs. Part D?

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

  • Are a U.S. citizen
  • Have 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 Prescription Drug plan. 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 initially 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 can change your coverage each year.

  • 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 the first day of the following month.   
  • 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.
  • Annual Enrollment Period – Each year, between October 15 and December 7, you can enroll in a Medicare Part D or MAPD plan for the first time or review your MAPD or Medicare Part D plan’s changes for the new year and make changes to your current plan. 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 plan will cover 100% of your remaining costs.

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Due to the passing of the recent Inflation Reduction Act, by 2025, all Medicare drug spending will be capped at $2,000 out of pocket. Thus, a plan will not be able to charge you more than $2,000 per calendar year for your prescription drugs.

However, your carrier and area of residence will determine the actual cost up to the maximum out-of-pocket limit. Unlike Medicare Supplement plans, your health will never be a factor in determining the cost of MAPD or Medicare Part D 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?

The best prescription drug coverage for you is determined by your drugs, budget, and location, as everyone has different needs. With many options, the right plan for you may not be the right one for your spouse or neighbor.

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 Medicare 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 simultaneously have a PDP through Medicare Part D and a MAPD. 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 have limitations on what prescription drugs it covers.
Do MAPD costs count toward my Advantage plan’s maximum out-of-pocket?
No, prescription costs do not count towards your Medicare Advantage plans 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 suitable 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://es.medicare.gov/publications/11109-Medicare-Drug-Coverage-Guide.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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