Medicare prescriptions, providers and benefits

Will I have prescription drug coverage?

Prescription drugs aren’t covered by Original Medicare (Parts A & B). Once you’ve enrolled in Medicare, there are two ways to get Medicare prescription drug coverage a stand-alone Medicare Part D prescription drug plan (PDP) or a Medicare Advantage plan with prescription drug coverage (MAPD).

2 ways to get Medicare prescription drug coverage
Medicare Prescription Drug (Part D) plan Medicare Advantage (Part C) plan

You can purchase a stand-alone Medicare Prescription Drug (Part D) plan to help pay for your prescription drug costs. You can have a stand-alone Part D plan in combination with any of these plans:

  • Original Medicare
  • Original Medicare plus a Medicare Supplement insurance plan
  • A Medicare Advantage Private Fee-for-Service plan that doesn’t include drug coverage
  • A Medicare Savings Account (MSA)

To get the convenience of having your prescription drug coverage in the same plan as your hospital, doctor and other benefits, you can look into a Medicare Advantage (Part C) prescription drug (MAPD) plan.

Most Medicare Advantage plans include prescription drug coverage and have a lower premium than a stand-alone Part D plan.

Remember: Each Medicare Advantage plan and stand-alone Part D plan covers a certain set of prescription drugs. Be sure to check each plan’s drug list (also known as a formulary) to see if the prescription drugs you take will be covered. If you already have prescription drug coverage, make sure your prescriptions will be covered by the plan each year, as a plan’s formulary can change from year to year, and the drugs they do or don’t cover can change, too.

Will I still be able to see my current provider(s)?

If staying with your current provider or doctor is important to you, check to see if a plan has a provider network. If it does, you’ll want to know if your doctor is in that plan’s network. Some plans will require you to stay in-network, while other plans allow you to use providers outside the network (sometimes at an additional cost), and still other plans don’t have a network at all. And Medicare supplement insurance plans let you see any provider or specialist without network restrictions, as long as they accept Medicare patients.

When thinking about plans, find out:

  1. Will I have to choose providers from a network? 
  2. Will my providers accept the plan’s terms? If not, are there providers near me who will?
  3. Will I need a referral from a primary care provider to see a specialist?
Providers and Medicare
  Originial Medicare (Parts A and B) Medicare Supplement (Medigap) plans Medicare Advantage (Part C) plans
Providers See any provider who accepts Medicare. See any provider or specialist without network restrictions, as long as they accept Medicare patients.

Network plans: If a plan has a provider network (for example, an HMO), you can save money by using a provider in the plan’s network. Some plans allow you to use providers outside the network, usually for a higher cost.

Non-Network plans: This type of Medicare Advantage plan may not have a provider network and allows you to see any provider that accepts Medicare and the plan’s terms.

Specialist referrals No referral needed to see a specialist who accepts Medicare. No referral needed to see a specialist. Some Medicare Advantage plans require a referral to see a specialist, some do not.
Providers and Medicare
  Providers Specialist referrals
Originial Medicare (Parts A and B) See any provider who accepts Medicare.

No referral needed to see a specialist who accepts Medicare.

 

Medicare Supplement (Medigap) plans

See any provider or specialist without network restrictions, as long as they accept Medicare patients.

 

No referral needed to see a specialist.
Medicare Advantage (Part C) plans

Network plans: If a plan has a provider network (for example, an HMO), you can save money by using a provider in the plan’s network. Some plans allow you to use providers outside the network, usually for a higher cost.

Non-Network plans: This type of Medicare Advantage plan may not have a provider network and allows you to see any provider that accepts Medicare and the plan’s terms.

Some Medicare Advantage plans require a referral to see a specialist, some do not.

Remember: If a plan has a provider network, that network can change each year. If your current plan has a provider network, be sure to check if your provider will be in the network next year. You can switch plans during the Medicare Annual Enrollment Period if your provider won’t be in your plan’s network next year.

Will I have coverage for additional benefits like vision, dental or hearing aids?

Original Medicare (Parts A & B) covers many medical and hospital services, but it doesn’t cover everything. Generally, Original Medicare won’t cover routine vision or dental care, eyeglasses, or hearing aids. However, many Medicare Advantage (Part C) plans include these additional benefits. Keep in mind that costs and benefits can vary from plan to plan. Be sure to watch for the additional benefits you need in the plan you’re considering.

Here are some other services that are not covered by Original Medicare:

  • Dental exams, most dental care or dentures

  • Routine eye exams, eyeglasses or contacts

  • Hearing aids or related exams or services

  • Most care while traveling outside the United States

  • Help with bathing, dressing, eating, etc. (custodial care)

  • Comfort items such as a hospital phone, TV or private room

  • Long-term care

  • Cosmetic surgery

  • Most chiropractic services

  • Acupuncture or other alternative treatments

  • Routine foot care

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