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What do Medicare Prescription Drug Plans Cover?

Understanding Medicare Prescription Drug Plans

Published: August 4, 2022

Category: Educational, Medicare Healthcare

Everyone on Medicare must choose whether they want drug coverage or not.  Even if you don’t use any prescription drugs, you should consider acquiring Medicare drug coverage to help cut your drug expenses now and safeguard against future needs and prescription drug rising costs. If you’re new to Medicare but already have other drug coverage, you have some new alternatives to think about. If you’re not new to Medicare, take a look at your choices to see if you can select drug coverage that better fits your needs.

Two Prerequisites to Obtain Medicare Prescription Drug Coverage

In order to qualify for prescription drug coverage, you must be enrolled in a Medicare program.  The original Medicare program offered by the U.S. Government has Parts A and B.  Inpatient hospital stays, skilled nursing facility care, hospice care, and certain home health care are all covered in Part A of the Medicare Program. Part B of Medicare provides some doctor’s services, outpatient treatment, medical supplies, and preventive services. It does not cover medicine.

The Medicare Prescription Drug Plan?

Everybody with Medicare can obtain prescription drug insurance coverage. If you don’t join a Medicare Prescription Drug Plan (Part D) when you first become eligible and don’t have any creditable prescription drug coverage or Extra Help, you can still apply for this coverage at a later date, but Medicare will charge a late enrollment penalty.

Two Options for Obtaining Drug Coverage

  • A Medicare Prescription Drug Plan.
  • A Medicare Advantage Plan (Part C), such as an HMO or PPO, or another Medicare health plan that provides coverage for prescription drugs.

To acquire Medicare prescription coverage, you must enroll in the original Medicare-approved plan or an approved plan offered by an insurance company or another private firm. The price and drugs covered by each plan may vary.

Do I Need a Medicare Drug Plan?

Before turning 65, you should look into your health care insurance to fully learn about its medical and drug coverage and costs as it may influence your choice to enroll in the Medicare drug coverage plan. Some forms of insurance provide prescription drug coverage that resembles Medicare and maybe worth keeping rather than enrolling in a Medicare drug plan. The following are some examples:

  • Federal Employee Health Benefits (FEHB) programs
  • Veterans’ Benefits

The above insurance policies are known as “creditable.” If you decide to join up for a Medicare drug plan in the future, you can keep them and avoid incurring a Medicare penalty.  If you don’t join when you’re initially eligible, Medicare may impose a penalty on your monthly payment. Many health plans supplied by employers and unions may also qualify as being creditable.

How is Medicare Coverage Organized?

If you decide you need Medicare drug coverage, it’s important to understand how the prescription drug portion of the program works into the wider scheme. Medicare is a government health-insurance program for adults 65 and above, as well as younger people with certain impairments and those with end-stage renal illness (kidney failure). Medicare divides into sections that provide different kinds of coverage that are categorized as Parts:

  • A – Includes inpatient hospital stays, skilled nursing facility care, hospice care, and certain home healthcare.
  • B – Includes some doctor’s services, outpatient treatment, medical supplies, and screenings and immunizations, among other things.
  • C – Medicare Advantage covers Parts A and B, as well as Part D. HMOs and PPOs, for example, are private health insurance firms that provide these plans.
  • D – The prescription drug coverage add-on to Medicare.

How do I Obtain Coverage?

Medicare enrollees can obtain prescription drug coverage in two ways:

  • Original Medicare (Parts A, B, or both) and special plans like Medicare Cost Plans, Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans can all contain prescription drug coverage. Part D, usually known as a prescription drug plan or PDP, covers you if you go this route.
  • It’s available as part of a Medicare Advantage Plan or another Medicare plan that includes prescription drug coverage (also known as an MA-PD). During open enrollment, you can move from a Medicare Advantage Plan that does not provide prescription drug coverage to one that does.

What will my Plan Cover?

Prescription drugs picked up at the pharmacy are covered by your Medicare prescription drug coverage plan. For example, it won’t cover drugs given to you by a doctor during a hospital stay or in an outpatient hospital environment.  It also excludes over-the-counter medicines like ibuprofen and Sudafed. However, it will cover certain drugs like insulin.

The Cost of Drugs Covered by Medicare

The cost of a Medicare prescription drug coverage includes a variety of factors including:

  • The premiums and cost-sharing that come with your plan.
  • The extent of your insurance.
  • The pharmacy that you go to.
  • Whether you reach the coverage gap, often known as the “donut hole.”
  • Whether or not you choose Medicare’s Extra Help program.

Let’s take a look at each one separately.

Cost-sharing and premiums

The majority of plans will demand that you pay a portion of your prescription drug costs (known as cost-sharing). Deductibles, coinsurance, and copays are all examples of cost-sharing. You will pay premiums as well. These expenses will differ depending on the plan.

  • A deductible pertains to an amount you pay for prescription drugs before your insurance kicks in (not all plans have deductibles).
  • After you’ve reached your deductible, you’ll pay coinsurance — a portion of prescription drug costs.
  • After you’ve reached your deductible, you’ll have to pay a copay for drugs.
  • The insured pays a monthly premium for prescription drug insurance.

Consider how much you can afford to spend for each prescription, as well as the overall expenses and coverage when picking a prescription drug plan. A plan’s premiums or deductibles may be costlier, but after you’ve reached the deductible, it usually provides enough coverage. The projected monthly Part D premiums by income are included in a table on the Medicare website. You must pay a monthly adjustment in addition to your premium if your income exceeds a particular threshold.

Covered Medications

When you look at plans, make sure that the ones you consider have a formulary that contains the prescriptions you use. A formulary is a list of drugs covered by a Medicare prescription plan. When your medicine isn’t on the formulary, you should ask your doctor if a similar drug is on the list or if they can assist you to acquire a coverage exemption. Medication is also divided into levels in certain plans. In general, the higher the tier, the greater the cost of the drug. Examine your prescriptions to see where they fall.

A generic drug, as opposed to a brand-name medication, normally costs less and provides greater coverage. Finally, check to see whether your plan imposes any limitations on your prescription coverage, such as prior approvals, step treatment, or quantity limits. These limits don’t always imply you won’t be able to acquire coverage for the medication. However, it may make acquiring insurance more difficult.

Extra Help

You should also think about whether you qualify for Medicare’s Extra Help program. Medicare will help cover your drug expenses, premiums, deductibles, and coinsurance if you fulfill the program’s eligibility and income conditions.

In Conclusion

For those considering the original Medicare Health Program or the Medicare Advantage Plans, you should investigate the different choices before applying for Medicare coverage. Depending on your circumstances, other creditable healthcare insurance choices may provide a better fit.