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MAPD vs. PDP Through Medicare Part D

Summary: Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug Plans both provide drug coverage to Medicare beneficiaries. Learn the differences between the two plan types in this article. Estimated Read Time: 6 min

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Table of Contents:

  1. What Does PDP Stand For in Medicare?
  2. MAPD Vs. PDP
  3. What Types of MAPD Plans are Available?
  4. What Types of PDP Plans are Available?
  5. Who is Eligible for MAPD vs. Part D?
  6. When Can I Enroll in an MAPD or Medicare Part D?
  7. How Much Do MAPD vs. Part D Plans Cost?
  8. Is It Better to Have PDP Vs. MAPD Coverage?
  9. MAPD vs PDP FAQs
  10. How to Decide Between MAPD vs. Medicare Part D Coverage

Original Medicare (Part A and Part B), offered through the federal government does not offer prescription drug coverage. However, you do have options available through private insurance carriers. Prescription drug coverage through Medicare typically comes in the form of a Medicare Part D Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug Plan (MAPD), depending on your health coverage.

Though similar, both MAPD and PDP Medicare coverage work differently, and while you can’t enroll in both plan types, one may be better suited for you over the other. It’s important to compare each plan type to understand which option works best with your needs. Below, we explore MAPD Vs. PDP plans and how Medicare to determine which option may be suitable for you.

What Does PDP Stand For in Medicare?

PDP is a shorter term for a Medicare Part D Prescription Drug Plan. Also known as Medicare Part D, these plans can be added on to your Original Medicare coverage to provide Medication benefits.  When you enroll in a Medicare Advantage HMO or PPO plan, you are unable to enroll in a standalone PDP. MAPD plans, or Medicare Advantage Prescription Drug Plans combine Original Medicare benefits with prescription drug coverage through Medicare Advantage.

MAPD Vs. PDP

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

On the other hand, Medicare Part D Prescription Drug Plans (PDP) are stand-alone plans that only provide prescription drug coverage through Part D coverage. Thus, your health 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 regulated by Medicare, covering certain drugs under its formulary. However, like MAPD coverage, Medicare Part D Prescription Drug Plans vary by location and provider. Some drugs may be on one carrier’s formulary and not another.

Additionally, you cannot simultaneously enroll in MAPD and Medicare Part D Prescription Drug 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.

MAPD plans may also have caveats, such as high out-of-pocket costs and restrictive networks. You also can’t have an MAPD when enrolling in a Medicare Supplement (Medigap) plan, as you still remain with Original Medicare and it’s illegal to have both at the same time.

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Everyone has different healthcare needs and it is essential to understand not only the right coverage for your healthcare and budget but also the benefits found in each plan in your area before you enroll.

medicare advantage prescription drug plans vs medicare part d plans.

What Types of MAPD Plans are Available?

Several types of Medicare Advantage plans include MAPD coverage, however, not all locations offer the same types of plans. The most common types of MAPD plans 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 less common types of Medicare Advantage plans to offer MAPD coverage are Private Fee-for-Service (PFFS) and Special Needs Plans (SNP):

Because MAPD plans also cover health benefits, only individuals 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 and accepts the plans payment terms. 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 Part D.

What Types of PDP Plans are Available?

Several Medicare Part D Prescription Drug plans are available through multiple carriers nationwide. Even in 2024, which is offering the fewest plans in the history of Part D, there are still more than 700 PDPs available nationwide. Unlike the different types of coverage that come with MAPD benefits, the basis of all Medicare Part D Prescription Drug plans is 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. This means checking each plan’s formulary before enrolling. Availability varies depending on location.

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 your current MAPD plan benefits to not meet your needs 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

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 approved 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 PDP Vs. MAPD 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.

MAPD vs PDP 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 the drug plan options available in your area.

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We have helped over 250,000 Medicare clients find their Medicare coverage

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 January 2024.
    https://www.medicare.gov/drug-coverage-part-d
  2. What Medicare Part D drug plans cover, Medicare. Accessed January 2024.
    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 January 2024.
    https://es.medicare.gov/publications/11109-Medicare-Drug-Coverage-Guide.pdf
  4. How do Medicare Advantage Plans work?, Medicare. Accessed January 2024.
    https://www.medicare.gov/types-of-medicare-health-plans/medicare-advantage-plans/how-do-medicare-advantage-plans-work
Jagger Esch

Jagger Esch

Medicare Educator
Jagger Esch is the Medicare Educator 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.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

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