| Thu, Nov 01, 2012 @ 09:00 AM

OEP Boot Camp: Check Your Prescription Drug Coverage

Posted by Medicare Made Clear

OEP Bootcamp Medicare prescription coverageThe fifth in a 6-post series designed to help you make informed Medicare choices for 2013

Prescription drugs can consume a big chunk of your health care dollar. This adds weight to decisions about drug coverage. Tack on the confusion of formularies, drug tiers and donut holes, and the decisions may seem overwhelming.

This is the next-to-last article in our Boot Camp series. It addresses prescription drug coverage—the last coverage consideration we will tackle. After this, we hope you’ll be in great shape for making your Medicare choices for 2013.

You Have Choices

You may have Medicare drug coverage through a standalone Part D prescription drug plan or as part of a Medicare Advantage plan. These are private plans offered by insurance companies. You may have several plans to choose from, depending on where you live.

Your main considerations in choosing a drug plan are:

  • Its formulary, which is the list of brand name and generic drugs it covers
  • Drug costs, which can vary from plan to plan
  • Its pharmacy network, which also can vary from plan to plan

Formularies and Drug Costs

You need to make a decision that helps you get the prescription medications you need at a price you can afford. Plans contract with drug companies and pharmacies to lock in prices for the drugs on its formulary. This can translate into savings for plan members.

Each plan determines which specific drugs will be on its formulary. This can change from year to year. You need to check your plan’s formulary for 2013 to make sure the drugs you take are covered. If your specific drug is not covered, your doctor may prescribe another similar drug that is on the formulary. Consult your doctor if you run into this situation.

Most plans have tiered formularies. The tiers define what drugs will cost. Usually drugs in lower tiers cost less. You’ll want to see which tiers include the drugs you take so you’ll know what your copays will be. Sometimes a drug in a lower tier can be substituted for one in a higher tier. You can request a generic version of a drug as well, which is generally cheaper than the brand name version.

You’ll also want to understand what your plan’s policy is regarding access to drugs not on the formulary. This varies from plan to plan.

Pharmacy Networks

Many plans have pharmacy networks. The individual pharmacies in each network agree to fill prescriptions and charge you the plan copay. You are assured of paying only your plan copay at these pharmacies.

The pharmacies in your plan network can change. If you have a particular pharmacy you like to use, then you may want to verify that it is in your plan’s 2013 network. You may also want to check whether your plan offers a mail order pharmacy option. Often you can save even more by purchasing a 90-day supply of your medication by mail.

If You Don’t Currently Have Drug Coverage

You can enroll in a Part D prescription drug plan for the first time during the Open Enrollment Period. You may have to pay a penalty, depending on two things:

  • When you were first eligible for Medicare
  • Whether you have had other comparable drug coverage, such as through an employer plan

You may be able to enroll in a 5-star Part D or Medicare Advantage plan without penalty. You can learn more about when you can join a drug plan at Medicare.gov.

Now What?

Prescription drug coverage is the last piece of the puzzle we’ve been putting together through this series. We hope you are close to seeing a clear picture of the Medicare coverage you need.

Our final Boot Camp series article will wrap it all up and provide tips for finding and comparing plans, as well as how to enroll.

Remember, the Medicare Open Enrollment Period ends December 7. You have just over one month to make your decisions and change your Medicare coverage choices, if you choose. In addition to this blog series, you can get help from these resources:

  • Medicare.gov, where you can download a copy of Medicare & You 2013, search for plans and find other helpful information
  • Private health insurance company web sites for information about 2013 Medicare Advantage (Part C) and Medicare prescription drug (Part D) plans
  • The 2013 Annual Notice of Changes mailed to you from your Medicare Part C or Part D plan, if you’re currently enrolled in one
  • A licensed health insurance agent in your community who can discuss all your plan choices with you

Be sure to report back to OEP Boot Camp for the final topic in this series, Decide and Take Action. Our goal is to help you make informed choices during the Open Enrollment Period.

For more information, 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. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


Medicare Videos: View videos that explain Part D prescription drug plans and more.

Review Your Current Medicare Coverage: Asking yourself these questions may help you decide whether you want to change your coverage choices.

Medicare.gov: Visit the official U.S. government site for Medicare.

Read other posts in this series:

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