Your Prescriptions Must Be Part of Your Medicare Decision

When comparing Medicare coverage, it's easy to focus on monthly premiums, doctor networks and additional benefits. But there's another question that's just as important: What about the medications you take every day?

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Prescription drug costs can vary from one Medicare plan to another. A medication covered affordably by one plan may be placed on a different cost-sharing tier by another. Your preferred pharmacy can matter. Plan rules can matter. And your prescription needs may change from year to year.

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That's why Gina believes your medication list should be part of the conversation when reviewing Medicare coverage.

At Rogue Valley Insurance Partners, she can help you understand how Medicare prescription drug coverage works and compare available options based on something much more meaningful than an advertisement:

The prescriptions you actually take.

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Understanding Medicare Part D

Medicare prescription drug coverage is commonly known as Medicare Part D. If you have Original Medicare, you can generally obtain prescription drug coverage by enrolling in a stand-alone Medicare Part D plan. If you choose Medicare Advantage, most Medicare Advantage plans include prescription drug coverage as part of the plan. Private insurance companies approved by Medicare offer Part D coverage, and plans can differ in premiums, deductibles, covered medications, pharmacy networks and what you'll pay when filling prescriptions.

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That's why there isn't one prescription drug plan that's automatically right for everyone. Your neighbor's plan may work wonderfully for your neighbor. That doesn't necessarily mean it's the best fit for you.

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What Is a Formulary?

Every Medicare drug plan has a list of prescription medications it covers. This list is called a formulary. When comparing plans, you'll want to determine whether the medications you take are included on that plan's formulary. But simply finding your medication on the list isn't always enough.

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Many plans organize covered drugs into different tiers. Generally, medications on lower tiers have lower cost sharing, while medications on higher tiers may cost more. Plans can structure their tiers differently, so the same prescription may not result in the same cost from one plan to another. Some medications may also have plan requirements such as prior authorization, quantity limits or step therapy.

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That's why Gina may ask you to bring a complete list of your medications—including the exact drug name, dosage and how frequently you take it—when reviewing your Medicare options. Those details can make a difference.

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Your Pharmacy Can Matter Too

Many people are surprised to learn that where they fill their prescriptions can affect what they pay. Medicare drug plans contract with pharmacies to create pharmacy networks. Depending on the plan, some network pharmacies may offer more favorable cost sharing than others. That means the pharmacy you've used for years may not necessarily be the most cost-effective choice under every plan you're considering. Mail-order pharmacy options may also be available. When reviewing prescription coverage, it makes sense to look at both sides of the equation: Which plan covers my medications appropriately? and Where should I fill those prescriptions under that plan?

This is another reason why comparing only monthly premiums doesn't tell the whole story.

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What If My Prescriptions Change?

Healthcare needs don't stand still. A medication you didn't need last year may become important this year. A physician may change your dosage, prescribe a different drug or discontinue a medication entirely. Drug plans can also make certain changes to their formularies. That's why reviewing your prescription drug coverage periodically—particularly when evaluating coverage for the coming year—can be valuable. When your medications change, the Medicare plan that made sense previously may still be a good fit. Or it may be worth comparing your options again.

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The goal isn't to change plans simply for the sake of changing. It's to make sure your coverage continues to make sense for the medications and healthcare needs you have today.

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Don't Overlook Part D Enrollment Timing

Even if you take very few prescription medications when you first become eligible for Medicare, don't automatically assume you can ignore Part D until you need it. Medicare has rules regarding creditable prescription drug coverage.

 

If you go without Medicare drug coverage or other creditable prescription coverage for 63 consecutive days or more after the applicable enrollment period, you may eventually owe a Part D late-enrollment penalty. That penalty generally isn't a one-time charge. It may be added to your Medicare drug plan premium for as long as you have Part D coverage. There are exceptions—for example, people receiving Medicare's Extra Help program don't pay the Part D late-enrollment penalty. The important point is simple: Understand your coverage before deciding to go without Part D.

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Help May Be Available With Prescription Drug Costs

If prescription costs are creating a financial burden, don't assume there's nothing you can do. Medicare has a program called Extra Help for people with limited income and resources. Those who qualify can receive assistance with certain Part D premiums, deductibles and prescription drug costs. Some people qualify automatically because they receive Medicaid, assistance through a Medicare Savings Program or Supplemental Security Income. Others may need to apply.

 

Eligibility requirements can change over time, so someone who didn't qualify previously may want to check again if their financial circumstances have changed. This is an area where asking questions can be worthwhile.

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Managing Higher Prescription Costs

Medicare drug coverage now includes an annual limit on what beneficiaries pay out of pocket for covered Part D prescription drugs. There is also a voluntary program called the Medicare Prescription Payment Plan. This payment option allows people with Medicare drug coverage to spread certain out-of-pocket prescription costs across the calendar year rather than paying those costs all at once at the pharmacy.

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There's an important distinction: The Medicare Prescription Payment Plan doesn't reduce the total cost of your medications. Instead, it may help some people manage the timing of those expenses by spreading payments over the remaining months of the calendar year. For someone facing relatively high prescription costs earlier in the year, that distinction can be helpful to understand.

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Questions Gina Often Hears

Does Original Medicare automatically include prescription drug coverage?
No. If you have Original Medicare and want Medicare prescription drug coverage, you generally need to enroll in a separate Part D plan.

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Do Medicare Advantage plans include prescription coverage?
Most do, but not all. The plan's specific drug coverage should always be reviewed before enrolling.

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Why does Gina need my medication list?
Because your actual prescriptions can help determine how well a plan's formulary and cost-sharing structure fit your needs. Drug name, dosage and frequency can all be important.

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Does it matter which pharmacy I use?
It can. Plans have pharmacy networks, and your costs may differ depending on the pharmacy you use.

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What if one of my medications isn't covered?
Depending on the circumstances, there may be alternatives or a coverage-determination and exception process available. Don't simply assume that you have no options.

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Is there help available if my prescriptions are expensive?
Possibly. Extra Help and other assistance programs may reduce costs for people who qualify. The Medicare Prescription Payment Plan may also help some beneficiaries manage the timing of their prescription expenses, although it doesn't reduce the total cost.

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Your Medicare Plan and Your Prescriptions Belong in the Same Conversation

Prescription drug coverage can seem complicated when you're looking at formularies, tiers, pharmacies, deductibles and plan rules. But you don't have to master all of that terminology yourself. Start with something much simpler: What medications do I take, and what matters to me?

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Gina can help you use that information to evaluate Medicare options available in your area and understand how prescription drug coverage fits into the larger Medicare picture. No guesswork based solely on an advertisement. No assumption that the lowest premium automatically means the lowest overall cost. Just a thoughtful review based on your individual situation.

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Let's Take a Look at Your Prescriptions

If you're new to Medicare, reviewing your current plan or simply wondering whether your prescription coverage still makes sense, bring Gina your medication list. Include the medication name, dosage, frequency and your preferred pharmacy.

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Call Gina today to schedule a no-obligation Medicare prescription drug coverage review.

A few minutes spent reviewing your medications could give you a much clearer picture of your Medicare options.