NATIONWIDE — Fall means pumpkins, cooler weather, apple cider and—for many people—it’s time to think about changes to your Medicare coverage. 

Yes, the fall annual election period began on Saturday, October 15. That’s when you can pick a new Part C (Medicare Advantage) provider, or change your Part D (prescription) coverage.

Or, naturally, you can keep things as they were. 

The election period lasts until Wednesday, December 7. Changes made will take effect January 2023.

About Part D

Medicare Part D, the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone prescription drug plan, for those enrolled in original Medicare, or as a set of benefits included with your Medicare Advantage plan.

You’ll need a Part D plan that meets your specific health care needs. But before you start looking at plans, make a list of the prescriptions you take, including their dosages and usual costs, and the pharmacies you regularly use.

Ask these questions about a Part D plan:

• Are my prescriptions on the plan’s formulary? 

The formulary is the list of prescription drugs for which a Part D plan will help pay. 

• Does the plan impose any coverage restrictions, such as prior authorization, step therapy or quantity limits? 

Prior authorization means that you must get approval from your Part D plan before the plan will pay for the drug.   

Step therapy means that your plan requires you to try a cheaper version of your drug before it will cover the more expensive one. 

Quantity limits restrict the amount of a drug you can get per prescription fill, such as 30 pills of Whatever Med per month. 

• How much will I pay at the pharmacy for each drug I need? 
• How much will I pay for monthly premiums and the annual deductible? 
• How much will I have to pay for brand-name drugs? How much for generic drugs? 
• Do I need to enroll in Part D if I have other coverage? 
• Do I need to enroll in Part D if I have job-based drug coverage? 

And note: There is no one best Part D plan for everyone. 

Medicare Advantage

While most people on Medicare get their health coverage from original Medicare, some choose to get their benefits from a Medicare Advantage plan (MA), also known as Part C. 

MA plans contract with the federal government and are paid a fixed amount per person to provide Medicare benefits. Remember: as with regular health insurance, MA plans may have different networks of providers, coverage rules, premiums (in addition to the Part B premium) and cost-sharing for covered services. 

Even plans of the same type offered by different companies could have different rules, so you should always check with a plan directly to find out how its coverage works.

Ask these questions about MA:

• Providers, hospitals, and other facilities: Will I be able to use my doctors? Are they in the plan’s network? Do doctors and providers I might want to see in the future take new patients who have this plan? If my providers are not in network, will the plan still cover my visits? Which specialists, hospitals, home health agencies and skilled nursing facilities are in the plan’s network? 
• Access to health care: What is the service area for the plan? Do I have any coverage for care received outside the service area? Who can I choose as my primary care provider (PCP)? Does my doctor need to get approval from the plan to admit me to a hospital? Do I need a referral from my PCP to see a specialist?  
• Costs: What costs should I expect for my coverage (premiums, deductibles, copayments)? What is the annual maximum out-of-pocket (MOOP) cost? Are there different limits for in-network and out-of-network care? How much will I have to pay out of pocket before coverage starts (the deductible)?  How much is my copayment for services I regularly receive, such as PCP or specialist care? How much will I pay if I visit an out-of-network provider or facility?  Are there higher copays for certain types of care, such as hospital stays or home health care? 
• Benefits: Does the plan cover any services that original Medicare does not (such as dental, vision, or hearing)? Are there any rules or restrictions?
• Prescription drugs: Does the plan cover outpatient prescription drugs? Are my prescriptions on the plan’s formulary?  Does the plan impose any coverage restrictions? What costs should I expect to pay for my drug coverage (premiums, deductibles, copayments)? How much will I have to pay for brand-name drugs? How much for generic drugs? What will I pay for my drugs during the coverage gap?  Will I be able to use my pharmacy? Can I get my drugs through mail order? Will the plan cover my prescriptions when I travel? 

Beneficiaries should keep their Medicare card in a safe place, because they’ll need it if they ever switch back to original Medicare.

Programs that can assist with the costs of medications:

There are income-based programs that could help offset the costs of prescriptions, such as EPIC, Extra Help or the Medicare Savings Program.  A HIICAP counselor will be able to assist you in finding out if you are eligible and even help you apply for the appropriate program. 

Medicare can be confusing

But it’s all right. Area offices for the aging can help you navigate the system.

In Sullivan County, NY, call the Office for the Aging at 845/807-0241.

In Wayne County, PA, call the Area Agency on Aging at 570/253-4262.

In Pike County, PA, call the Area Agency on Aging at 570/775-5550 ext. 1313.