October 6, 2021
Prescription drugs are an integral part of health care. If you don’t have insurance coverage for them, they can also end up being the most expensive. If you’re on Medicare, you might be wondering how your prescriptions are covered by the plan. This guide will walk you through which prescriptions are covered by which parts of Medicare. We’ll help you learn about comparing Medicare Part D plans, and we’ll answer some of the most common questions about getting your prescriptions as a Medicare beneficiary.
Does Medicare cover prescriptions?
Only certain parts of Medicare cover prescriptions. It’s important to understand which plans provide coverage for your specific medications. Generally, you’ll need to purchase a Part D plan or a Medicare Advantage plan to have coverage for the prescriptions you get from the pharmacy. Medications you get at a hospital or skilled nursing facility are usually covered under Medicare.
Do I need stand-alone prescription drug coverage?
If you’re enrolled in Original Medicare (Parts A and B), you can get stand-alone prescription drug coverage with a Medicare Part D plan. Your plan options depend on where you live, what you’d like covered, and your individual budget. If you don’t purchase a Part D plan, your prescription costs will come completely out-of-pocket.
The only time you don’t need stand-alone prescription drug coverage is if you’re enrolled in a Medicare Advantage plan that already includes prescription drug coverage. These are commonly referred to as “MA-PD” plans, which stands for Medicare Advantage Prescription Drug. (Not all Medicare Advantage plans include prescription drug coverage.)
Which prescriptions are covered by Parts A and B?
Medicare Part A covers hospital treatment. As long as you have Medicare Part A during your stay at a hospital or skilled nursing facility, Part A will pay for the prescriptions you need throughout your stay. The prescriptions you receive as part of home health care arrangements may also be covered with Part A.
Medicare Part B covers visits to your doctor. It will pay for certain vaccines and most medicines that your doctor administers at clinics or dialysis centers. Medicines covered under Part B have to be purchased and supplied by your doctor, clinic, or dialysis center. Part B also covers oral chemotherapy medicines that you take at home.
Which prescriptions are covered by Part C?
Medicare Part C (Medicare Advantage) combines Parts A and B along with other types of coverage. It covers all of the aforementioned drugs that you’d get through Parts A and B. If you have an MA-PD plan (Medicare Advantage that also includes prescription drug coverage), your coverage is determined by your plan’s insurance provider. This can vary between insurance companies, plans, and even your location.
Which prescriptions are covered by Part D?
Medicare Part D covers most of the prescriptions you take at home, including those that you get at pharmacies and from mail order pharmacies. It covers drugs that are not covered through other parts of Medicare. Part D is provided by private insurance companies that are authorized by Medicare. Since each Part D plan is different, your out-of-pocket costs and coverage requirements might be different from the costs and requirements that your friends and family members have.
Each Part D plan has a different list of covered medicines. This list is called a formulary. Your plan has to inform you if the list changes, and it’s important to understand that most lists favor generic medicines over often more expensive name brands.
What should I look for when comparing Medicare Part D plans?
Each Part D plan has an annual deductible, a monthly premium, copayments (flat fees for each prescription), and coinsurance (a percentage of the drug’s actual cost). You should compare all of these costs when shopping for Part D plans. If you currently take prescriptions, you’ll also want to check each plan to determine whether your medicine will be covered.
As you look at how plans cover your current medicines, make sure to see if your regular pharmacy is included in the plan’s network. You should also check to see if the plan offers a mail-order pharmacy. On some plans, mail-order pharmacies may provide better savings than your regular pharmacy.
What if Medicare doesn’t cover my prescription?
Some Medicare Part D plans may require you to try step therapy before paying for an expensive medication. In these cases, your doctor will need to prescribe less expensive medication first, and you’ll be monitored to see if you respond. Then, if the less expensive medicine is not effective for you, Medicare will pay for the more expensive drug.
If your plan doesn’t pay for a particular medicine, you may be able to for an exception. Medicare may approve your request if your doctor believes it’s medically necessary for you to receive that specific drug. If that doesn’t work, Medicare has an appeals process for these situations.
Where can I get help with Medicare Part D comparisons?
SmartMatch is here to help you with all of your Medicare comparison shopping needs. Whether you’re considering a stand-alone Part D plan or an all-inclusive Medicare Advantage plan, our licensed insurance agents can help you compare and contrast your options in one simple phone call. Give us a call or visit our Plan Comparison Tool to make your Medicare shopping experience easy.