Medicare Drug Costs: You Have ChoicesPosted by Medicare Made Clear
Prescription medications that you take regularly are a constant and visible health care expense. Each time you fork over your share of the cost for a refill, you are reminded that Medicare doesn’t pay for everything.
It only makes sense to know how much you will have to pay for your drugs over the course of a year when you’re choosing a plan. During Open Enrollment (Oct. 15 – Dec. 7), it’s a good idea to review your current drug coverage, including any changes that may be coming in January.
The Annual Notice of Changes you get from your plan will explain what cost or benefit changes to expect, if any.
You may want to pay particular attention to changes in your drug coverage and costs. What you learn could help you decide whether to stick with your current plan or make a change during Open Enrollment.
Here’s what to look for.
Are the drugs you take covered?
Check your plan’s formulary to make sure your prescribed medications are on it. Formularies may change from one year to the next. You need to verify that your drugs will be covered, even if they have been in the past.
Your plan is required to provide you with a complete list of covered drugs for the coming year. The most common ones may be mentioned in your Explanation of Coverage, a document your plan sends to you in the fall. You may have to call your plan or go to its web site to get the full formulary list.
If your drug isn’t on your plan’s formulary, you may want to talk to your doctor before deciding to change plans. You may be able to get an exception that allows you to keep taking the drug, or an alternative medication may be available.
Which formulary tiers are your drugs included in?
Many Part D plans have tiered formularies. Plans place each covered drug in a tier, and the placement may vary from plan to plan. For example, a drug may be in tier 1 of one plan and tier 2 of another. The tier placement determines what plan members will pay out-of-pocket for that drug. Drugs in low tiers generally cost less than drugs in high tiers.
Your plan may move drugs to different tiers from one year to the next. It’s important to double check which tiers the drugs you take are in. Changes may affect what you will pay for refills. Of course, drugs may be moved from a high tier to a lower tier, which could save you money.
Talk to your doctor if you find that a drug you take has been moved to a higher tier and will cost you more. There may be a similar medication in a lower tier that you can switch to. If not, you may want to look at other plan choices.
Is the pharmacy you use still in your plan’s network?
Just as your plan’s drug formulary can change, so too can its pharmacy network. Plans contract with pharmacies to establish pricing for covered drugs. In general, plan members may save money by using a network pharmacy.
When you review your plan’s pharmacy network, you may also want to check to see if the plan offers a mail-order pharmacy benefit or 90-day refills. This could help you save more on your drugs.
Do you have specific needs to consider?
Some prescription drug plans restrict the use of certain medications. These may include 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 medication needs are affected. Restrictions may include requirements for prior authorization, quantity limits or step therapy.
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.
Choosing a Medicare Prescription Drug Plan: Learn more about Medicare Part D plans.
Medicare Plan Finder: Find and compare Medicare plans.
Medicare & You: Get the official U.S. government Medicare handbook.