| Tue, Nov 01, 2016 @ 09:00 AM

4 Basic Questions to Ask about Your Medicare Part D Coverage

Posted by Medicare Made Clear

questions-about-drug-coverage-for-seniorsPrescription drugs that you take regularly are a constant and visible health care expense. Every time you fork over your share of the cost for a refill, it’s a reminder that Medicare doesn’t pay for everything.

It only makes sense, then, to stay on top of your drug plan benefits and costs. As you may know, each Medicare Part D plan and Medicare Advantage (Part C) plan with drug coverage decides which drugs it covers and how much plan members pay. And coverage and costs may change each year.

Where to Get Medicare Part D Plan Information

Your Medicare Part D or Medicare Advantage plan sends you two documents each fall:

  • The Evidence of Coverage gives details about plan benefits, costs, and other information.
  • The Annual Notice of Change explains changes to benefits, costs or service area that will go into effect on January 1.

These documents are your guide to understanding your Medicare Part D coverage for the upcoming year. You may also receive a drug list, which is called a “formulary.”

Keep the following 4 questions in mind when you review your plan materials. The answers may help you decide whether your current Medicare Part D coverage meets your needs. If not, you may choose a different plan during Medicare Open Enrollment, Oct. 15 – Dec. 7.

1. Does your plan cover the drugs you take?

Medicare Part D and Medicare Advantage plans with drug coverage may change the drugs they cover from one year to the next. You need to find out if your drugs will be covered in the coming year.

The most common covered drugs may be listed in your plan’s Evidence of Coverage. You may visit the plan web site or call customer service to get the full drug list.

You may want to talk to your doctor if you learn that your drug is not covered. You could get an exception that allows you to keep taking the drug, or there may be a different covered drug that you can take. Otherwise, you may want to look for a different plan.

2. Will your drug costs change?

Most Medicare Part D and Medicare Advantage plans with drug coverage share the cost of your drugs with you through co-pays or co-insurance. Some plans also have a deductible that you have to meet before it starts helping with your drug costs.

Plans may change their cost-sharing terms each year. Your co-pay or co-insurance amounts may go up or down. Your plan deductible or premium may change as well. These changes are explained in the Annual Notice of Change.

Your drug costs could also change if a drug you take is moved to a different level in a tiered formulary. Tier placement determines what plan members pay for a drug. Drugs in low tiers generally cost less than drugs in high tiers. Your plan must notify you of tier changes that affect you, but it’s a good idea to check the drug list yourself.

Talk to your doctor if your cost for a drug you take is going up. There may be a similar covered drug that you can switch to. If not, you may want to look at other plan choices.

3. Is your pharmacy in the plan’s network?

Your Medicare Part D and Medicare Advantage plan may also change its pharmacy network. Plans contract with pharmacies to offer plan members set pricing for covered drugs.

In general, you may save money by using a network pharmacy. Some plans offer a mail-order pharmacy benefit or 90-day refills, too, that could help you save more on your drugs.

4. Do you have special health needs to consider?

Some Medicare Part D and Medicare Advantage plans restrict the use of certain drugs. Restrictions may be set on high-cost drugs or drugs that may be abused, such as pain medications.

People with chronic conditions or other special situations may want to explore their plan’s “utilization management restrictions” to see if any of their drug needs are affected. Restrictions may include the following:

  • Prior authorization: The plan must approve a prescription before it can be filled.
  • Step therapy: You must try certain drugs to treat a medical condition before other drugs to treat the same condition will be covered.
  • Quantity limits: The plan limits the amount of a drug that it will cover.

All of this information should be explained in the Evidence of Coverage and Annual Notice of Change you receive from your plan. Call your plan’s customer service number if you have questions.


Drug costs are a concern for many Medicare beneficiaries. It’s a good idea to review your Medicare Part D coverage and any changes going into effect on January 1. You may keep your current plan or choose a different Medicare Part D or Medicare Advantage plan during Medicare Open Enrollment (Oct. 15 – Dec. 7).

Related Content

Open Enrollment Starts October 15

Choosing a Medicare Prescription Drug Plan (PDF)

Medicare Plan Renewal: Not Deciding Is a Decision


For more information, explore MedicareMadeClear.com or contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048.

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