| Wed, Oct 30, 2013 @ 09:00 AM

Review Your Prescription Drug Coverage: Medicare Open Enrollment Boot Camp

Posted by Medicare Made Clear

Prescription drugsThe sixth in a series of eight articles to help you make informed Medicare coverage decisions

Prescription drugs are critical to health and a significant expense for many people. This makes decisions about Medicare drug coverage especially important.

The most recent article in this series discussed the need to understand your current Medicare coverage and any changes Medicare or your plan may have made for 2014. If you missed that article, you can view it now.

This article goes a little deeper into understanding your current prescription drug coverage and what you need from it.

How You Get Your Drug Coverage

You have two ways to get Medicare prescription drug coverage.

  • If you have a Medicare Advantage plan (Part C), your plan most likely includes drug coverage as part of the plan benefits. Medicare Advantage plans also provide all the benefits of Original Medicare (Parts A and B) and often additional coverage such as vision and dental care.
  • If you receive your Medicare benefits through Original Medicare (Parts A and B), you may have purchased a standalone Medicare prescription drug plan (Part D) that provides your drug coverage. Original Medicare does not cover prescription drugs.

Medicare Advantage and prescription drug plans are offered by private insurance companies where you live. You may have many plans of either type to choose from, depending on your needs and where you live. It’s important to note that with most Medicare Advantage plans, you are unlikely to have or need a standalone Medicare prescription drug plan.

Some Medicare Advantage plans and most standalone prescription drug plans charge a monthly premium (in addition to the Part B premium you pay to Medicare). Plans may also charge a deductible, and you will likely pay a copay each time you fill a prescription.

Check Plan Formularies

Each plan, whether a standalone drug plan or a Medicare Advantage plan with drug coverage, decides which drugs it will cover. The list of covered drugs is called a “formulary.” Drug formularies may vary between the plans offered where you live and from plans offered elsewhere in your state or in other states.

Drug formularies are often “tiered.” A tiered formulary divides drugs into groups based primarily on cost. A plan’s formulary might have three, four or even five tiers.

Each plan decides which drugs on its formulary go into which tiers. The decision is based on what the plan pays for the drug. In general, the lowest-tier drugs are the lowest cost. Lower-priced drugs are often listed as “preferred” drugs. Generic drugs are often lower-cost drugs.

Review the plan details of your current drug coverage and any other drug plan you may be considering. With a list of your current medications on hand, ask:

  • Are my current medications on the plan formulary?
  • If my drug is not on the formulary, is there a substitute that would work for me? (Ask your doctor to help with this.)
  • What tiers are my medications on?
  • What will I pay out of pocket (copay) for drug refills?

You may want to write this information next to each drug on your list of medications. Keep the list in your Medicare file for reference as you narrow down your plan choices.

For each plan, you will also want to know:

  • What pharmacies you can use. Some plans require you to use a pharmacy within their contracted network.
  • Whether the plan has a mail-order pharmacy benefit that may save you money. You may be able to mail-order a 90-day supply of certain drugs for a single copay.

Stay With Us!

View our next post in the series that explores finding and comparing Medicare plans. Open Enrollment ends December 7, so you have just over one month to make your decisions and change your Medicare coverage choices, if you choose.

Check out all of our Boot Camp series articles. Be prepared to make an informed decision about your Medicare coverage for 2014. In addition, you can get help from these resources:

  • Medicare.gov, where you can download a copy of Medicare & You 2014, search for plans and find other helpful information.
  • Private health insurance company web sites for information about 2014 Medicare Advantage (Part C) and Medicare prescription drug (Part D) plans.
  • A licensed health insurance agent in your community who can discuss all your plan choices with you.

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.


Choosing a Medicare Prescription Drug Plan: Get tips about what to look for in a drug plan.

Medicare Prescription Drug Plans: Watch a video to learn more about prescription drug coverage.

Medicare & You: Learn about Original Medicare coverage and costs in this annual publication.

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