Nearly 9 in 10 older adults take prescriptionmedication. But medications can be expensive, so it’s important to have an insurance plan that covers them.
Medicare Advantage, also called Medicare Part C, can help with that. Here’s what you need to know.
What Is Medicare Advantage (Medicare Part C)?
The U.S. government offers health insurance for adults 65 and over. This insurance program is called Medicare, also known as original Medicare.
There are four categories of Medicare plans:
Part A: Hospital insurance. Covers some of the costs of hospitalizations
Part B: Medical insurance. Helps pay for regular doctor visits
Part C: Medicare Advantage. Private insurers paid by Medicare cover your benefits.
Part D: Drug coverage. Helps pay for prescriptions
Medicare Advantage is a comprehensive insurance package. It bundles hospital insurance (Part A), medical insurance (Part B), and sometimes drug coverage (Part D).
When choosing a plan, there are a few things to consider. Some are:
- Are prescription drugs covered? If so, which ones?
- What are the plan’s coverage rules?
- Does this plan cover local pharmacies? Does it offer mail delivery?
- What will my out-of-pocket costs be?
Does Medicare Advantage Cover Prescription Drugs?
Most, but not all, Medicare Advantage plans cover prescription drugs. The plans that cover drugs are bundled with Medicare Part D. These are called Medicare Advantage Prescription Drug (MAPD) plans. MAPD plans cover several generic and name-brand drugs. But they don’t cover everything. You still might pay a copay or deductible.
If you choose a Medicare Advantage plan that doesn’t cover prescriptions, you may be able enroll in a separate plan for prescription coverage. This is called a prescription drug plan (PDP). Whether you can depends on what type of Medicare Advantage plan you have.
- You can get an additional PDP if you have an MSA, Medicare Cost Plan, or some PFFS (Private Fee-for-Service) plans.
- You cannot get an additional PDP if you have an HMO, HMO POS, or a PPO plan. If you have one of these plans and enroll in a PDP plan, you'll lose your Medicare Advantage plan.
Name-Brand vs. Generic Drugs
There are store-brand versions of most products at the grocery store. Medications work the same way. The FDA requires drug companies to prove that their generic version has the same active ingredients, safety, and strength as the brand-name drug.
The main difference? Generic drugs are usually much cheaper. But keep in mind that not every drug has a generic option available.
How to Know if Your Prescription Is Covered
Every MAPD plan has a list of drugs (both prescription and generic) it covers. This list is called a formulary. It’s organized by drug classes and categories, such as antibiotics, beta-blockers, etc. These tell you what the drugs are used for and how they work.
MAPD plans generally must cover at least two drugs in each category. They also must cover most drugs in protected classes. The protected classes are:
- Antipsychotics
- Antidepressants
- Anticonvulsants
- Immunosuppressants
- Cancer drugs
- HIV and AIDS drugs
Occasionally, an insurance plan will update its formulary during the year. This can happen for several reasons, including:
- New drugs being approved
- Safety concerns with existing drugs
- New medical information
These changes can happen at any time. Sometimes it’s right away, like when the FDA decides a drug isn’t safe. Otherwise, if the change affects a drug you’re currently taking, the plan must let you know. It can either:
- Give you 30-day notice
- Give you written notification and at least a 30-day supply of your medication at its current cost. This happens when you refill your prescription.
After 30 days, you’ll need to change to a similar drug listed in the formulary. If that isn't possible, you can pay full price for your original drug or ask the insurance company for an exception.
The formulary changes every year, so it’s important to check for updates when you re-enroll in your plan each year. This information should also be included in an Annual Notice of Change document sent by the company.
Drug Coverage Rules
Some insurance companies have rules about when they’ll pay for certain drugs. They include:
Prior authorization. This is when your doctor has to show the insurance company that you meet certain conditions before they’ll cover a medication. If you don’t, you or your doctor can ask for an exception.
Step therapy. Sometimes, insurance plans won’t pay for an expensive drug until you try a generic or low-cost version first. If the low-cost drug doesn’t work or triggersside effects, then they’ll cover the more expensive drug. If your doctor thinks you need the more expensive drug right away, they can ask for an exception.
Quantity limits. Some insurance plans limit how much of a certain drug you can get. For example, they might cover a 30-day supply of medication, but not a 90-day supply.
Opioid pain medication safety checks. Opioid pain medication can be very addictive. To keep you safe, some plans have extra safety checks to make sure you’re using the medicine in a healthy way. For example, you may only be given a 7-day supply if you’ve never used opioids before.
What Will My Prescription Cost?
Even if a medication is covered, you still might have to pay part of the cost. This is called a copayment. You can find this information in the formulary. It tells you which price tier each drug falls under. The lowest tier is the most affordable, and the highest tier is the most expensive. Each plan has a different tier system, decided by the insurance company. It might look like this:
Tier 1. Mostly generic drugs, with a low copayment.
Tier 2. Mostly brand-name drugs, with a copayment that falls in between low and high.
Tier 3. Rarely used or specialty brand-name drugs with a high copayment.
Getting Your Medications
Most people get their medications in person at a pharmacy. Some plans cover mail-order delivery. This is when your drugs come in the mail. It’s a convenient option for people who can’t make it to the pharmacy for whatever reason.
What if My Medication Isn’t Covered?
Plans usually cover a similar drug in the same category. But if none of the covered drugs work for you, you can ask for an exception. Follow these steps to asking for an exception:
- Ask your insurance company for a coverage determination. This is a written document that explains why they won’t cover a medication.
- Ask your provider for a written statement explaining why you need this particular drug.
- Submit your written request for an exception to the insurance company. Include your doctor’s note.
- Wait for the insurance company to make a decision.
- If you disagree with the company’s decision, you can submit an appeal to reconsider their decision.
Call your insurer to find out how to do this. You and your doctor may be able to fill out forms online. Or they may require you to mail everything. Their contact information is on your membership card. You can find it on their website, too.
Money-Saving Tips
Insurance can make prescription drugs more affordable, but there are ways to lower the price even more. Here are some tips.
Go generic. Prescription and generic drugs are nearly identical, but generic drugs cost up to 95% less. When your doctor prescribes a medication, ask if there is a generic option available.
Buy in bulk. Sometimes it’s cheaper to get a 90-day supply of medication than a 30-day supply. Check with your insurance company to see if they’ll allow this.
Compare pharmacy prices. Just as grocery stores charge different prices for the same brand of orange juice, pharmacies charge different prices for drugs. Compare the costs at a few local pharmacies. Their price lists can be hard to find, so call them to ask how much they charge for your medication.
Choose an in-network pharmacy. Some insurance companies partner with “in-network” or “preferred” pharmacies. This may offer you savings. Ask your insurance company how to find a preferred pharmacy near you.
Read your “Evidence of Coverage” document. The insurance company will send this to you once a year. It tells you about your benefits, coverage rules, how to request an exception, and more. Knowing this information can help you make money-wise decisions.
Each Medicare Advantage plan has different approaches to drug coverage. Choosing the right one can help you manage costs and stay healthy. When in doubt, never be afraid to ask your insurance company for more information.
Show Sources
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SOURCES:
Medicare.gov: “How to get prescription drug coverage,” “How Medicare plans use pharmacies, formularies, and common coverage rules,” “How Medicare prescription drug coverage works with a Medicare Advantage Plan or Medicare Cost Plan,” “What Medicare Part D drug plans cover,” “What’s a Medicare Advantage plan?”
Merck Manuals: “Aging and Medications.”
National Council on Aging: “Are Prescriptions Covered Under Medicare Advantage Plans?”
