4 basic questions to ask about your Medicare Part D coverage

Published by Medicare Made Clear®

Prescription drugs that you take regularly are a constant and visible health care expense. Every time you fork over your share of the cost for a refill, it’s a reminder that Medicare doesn’t pay for everything.

So it only makes sense, then, to stay on top of your drug plan benefits and costs. As you may know, each Medicare Part D plan and Medicare Advantage (Part C) plan decides which specific drugs are covered and how much you will pay. And because coverage and costs may change each year, it’s a good idea to ask some questions when you’re evaluating your Part D or Medicare Advantage plan for prescription drug coverage.

Where to get Medicare Part D plan change information

Before we dive into what questions to ask about your plan, let’s look at where to find out what changes your plan has made to its costs and covered benefits.

Your Medicare Part D or Medicare Advantage plan sends you two documents each fall:

  • The Evidence of Coverage gives details about plan benefits, costs, and other information.
  • The Annual Notice of Change explains changes to benefits, costs or service area that will go into effect on January 1.

These documents are your guide to understanding your Medicare Part D coverage for the upcoming year. You may also receive a drug list, called a “formulary,” that will identify what drugs are covered by the plan.

Now that you know where to look, here’s what to ask. Keep the following four questions in mind when reviewing your plan materials. The answers may help you decide whether your current prescription drug coverage meets your needs. If not, you may consider choosing a different plan during Medicare Annual Enrollment, Oct. 15 – Dec. 7.

1. Does your Medicare plan cover the drugs you take?

Medicare Part D and Medicare Advantage can change the drugs they cover from one year to the next. You need to find out if your drugs will (still) be covered in the coming year.

The most commonly covered drugs may be listed in your plan’s Evidence of Coverage. You’ll also want to check the plan’s formulary if you’re sent one. Since plans can cover a lot of drugs, you may not receive documentation for the entire list of covered drugs. A good tip is to visit the plan provider’s website or call customer service to get the full drug list.

Tip: You may want to talk to your doctor if you learn that your drug is not covered. You could get an exception that allows you to keep taking the drug, or there may be a different covered drug that you can take that is covered by your current plan. Otherwise, you may want to look for a different plan with the drug you need.

2. Will your drug cost more?

Most Medicare Part D and Medicare Advantage plans share the cost of your drugs with you through copays or coinsurance. Some plans also have a deductible that you have to meet before it starts helping with your drug costs.

Plans may change their cost-sharing terms and overall costs each year. Your co-pay or co-insurance amounts may go up or down. Your plan deductible or premium may change as well. These changes are explained in the Annual Notice of Change letter you’ll get.

Your drug costs could also change if a drug you take is moved to a different level in a tiered formulary. Tier placement determines what plan members pay for a drug. Drugs in low tiers generally cost less than drugs in high tiers. Your plan must notify you of tier changes that affect you, but it’s a good idea to check the drug list yourself.

Talk to your doctor if your cost for a drug you take is going up. There may be a similar covered drug that you can switch to that costs less. If not, you may want to look at other plan choices.

Savings tip: Brand name drugs will cost more than generic, so talk with your pharmacist about potential alternatives that may be less expensive that are covered on your plan’s drug list.

3. Is your pharmacy in the plan’s network?

Your Medicare Part D and Medicare Advantage plan may also change its pharmacy network. Plans contract with pharmacies to offer plan members set pricing for covered drugs.

In general, you may save money by using a network pharmacy. Some plans offer a mail-order pharmacy benefit or 90-day refills, too, that could help you save more on your drugs.

4. Do you have special health needs to consider?

Some Medicare plans restrict the use of certain drugs. Restrictions may be set on high-cost drugs or drugs that may be abused, such as pain medications.

People with chronic conditions or other special situations may want to explore their plan’s “utilization management restrictions” to see if any of their drug needs are affected. Restrictions may include the following:

  • Prior authorization: he plan must approve a prescription before it can be filled.
  • Step therapy: You must try certain drugs to treat a medical condition before other drugs to treat the same condition will be covered.
  • Quantity limits: The plan limits the amount of a drug that it will cover.

All of this information should be explained in the Evidence of Coverage and Annual Notice of Change documents you receive from your plan, but call your plan’s customer service number if you have questions.

Remember: Always review your drug coverage each year

Drug costs and proper coverage are a concern for many Medicare beneficiaries. Again, it’s a good idea to review your Medicare drug coverage and any changes going into effect the following year. 

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Medicare Made Clear brought to you by UnitedHealthcare provides Medicare education so you can make informed decisions about your health and Medicare coverage.

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