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What Is Covered by Medicare Part C & D?

Wading through Medicare regulations can be time-consuming and confusing, especially since the advent of Part D prescription drug coverage. If you're trying to simplify your Medicare experience, you might want to join a Medicare Advantage plan, also known as Medicare Part C, that administers everything for you, including Parts A, B and D. If you prefer to keep your original Medicare and use a Part D drug provider, read each plan's list of covered drugs to ensure that your medications are on it.

  1. Medicare Part C Basics

    • Medicare Advantage Plans are sometimes referred to as Medicare Part C. Offered by private companies, these plans provide all of the benefits that are available under Medicare Parts A and B except for hospice care, which is still covered by your original Medicare. They also provide prescription benefits that normally would be covered under Medicare Part D. If you choose to join a separate Medicare drug plan, you'll lose your coverage under the Medicare Advantage Plan and will be covered under original Medicare instead.

      In addition to your Part B premium, you might have to pay a monthly premium for Medicare Advantage. These plans can also charge deductibles, co-payments and premiums for extra coverage, mandate whether you need referrals to see specialists and whether you're limited to using doctors and hospitals that belong to your plan.

    Types of Medicare Advantage Plans

    • According to the "Medicare and You" brochure available from Medicare, the five types of Medicare Advantage Plans, or Medicare Part C providers, are as follows: Health Maintenance Organizations (HMO) Plans; Preferred Provider Organizations (PPO) Plans; Private Fee-for-Service Plans (PFFS) Plans; Medical Savings Account (MSA) Plans; and Special Needs Plan (SNP).

    Coverage

    • HMOs, SNPs and PPOs usually provide prescription coverage, while PFFS and MSA plans don't. If your plan doesn't cover prescriptions, you can join a Part D prescription drug plan.

      If your plan is an HMO or SNP, you'll have to receive care from its doctors and health care facilities. PPOs also have their own doctors and facilities, but you can choose to go elsewhere if you're willing to pay extra. PFFS and MSA plans pay for any doctor or facility that participates in their plans. You're free to use other providers, but you'll pay more.

      HMOs and SNPs usually require referrals for specialists, while the other types of plans don't. The exceptions for HMOs and SNPs are screening mammograms, pelvic exams and Pap smears, which don't require referrals.

    Medicare Part D Basics

    • You must be eligible for Medicare Part A, Part B or both in order to qualify for Medicare Part D. Your plan will send you a card to use for prescriptions and information about your coverage. Plans can vary, but all are required to provide at least a basic level of coverage as required by Medicare. Each plan has its own formulary, or list of covered drugs, and should provide you with a copy. You might have to get prior authorization before some prescriptions are filled, and you might have to try lower-cost drugs before a prescribed higher-cost drug is authorized.

      All Part D plans are required to pay for preventive vaccines, such as the Zoster vaccine for shingles, unless they're covered under Part B. If you are given drugs in an emergency room or outpatient facility and they aren't covered by Part B, they might be reimbursed by Part D.

    Contact Information

    • Questions about coverage under your Medicare Advantage Plan can be directed to the customer service telephone number for your plan. For information about different plans, go to the Medicare website, which is Medicare.gov, and click on "Compare Health Plans and Medigap Policies in Your Area," or call 1-800-MEDICARE (1-800-633-4227).

      You can get information about the various Part D prescription plans by using the second Medicare website link in the References section or by calling 1-800-MEDICARE (1-800-633-4227) and saying "Drug Coverage." If you're already enrolled in a plan, call its customer service number for information about coverage.

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