Medicare Prescription Drug Coverage
Basic Information
What is Medicare Part D?
Medicare offers prescription drug coverage for everyone with Medicare. This coverage is called "Part D." To get Medicare drug coverage, a person must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If a person wants Medicare drug coverage, he or she needs to choose a plan that works with their health coverage.
How to Get Coverage
There are generally two ways to get Medicare prescription drug coverage: join a Medicare Prescription Drug Plan (PDP) or a Medicare Advantage (MA) Plan. A person can also enroll in an employer or union-sponsored plan. To join a Medicare Prescription Drug Plan, a person must have Medicare Part A and/or Part B. To join a Medicare Advantage Plan (like an HMO or PPO), a person must have Part A and Part B. The person must also live in the service area of the Medicare drug plan he or she wants to join.
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How Drug Plans Work
Medicare Prescription Drug Plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
Medicare Advantage (MA) Plans, like a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), or another Medicare health plan each include prescription drug coverage. People get all of their Medicare coverage, including prescription drugs, through these plans.
Coverage by Other Drug Plans
If a person has prescription drug coverage from a former or current employer or union, contact the plan's benefits administrator before making any changes to the drug coverage. Joining a Medicare drug plan could change how the person's employer or union coverage works, both for the person and any dependents covered by the plan.
Also, if a person has prescription drug coverage from TRICARE, the Department of Veterans Affairs (VA), or the Federal Employee Health Benefits Program (FEHBP), contact the plan's benefits administrator or insurer before making any changes. In most cases, it will be to the person's advantage to keep the current coverage. However, in some cases, adding Medicare prescription drug coverage can provide extra coverage and savings, especially if the person qualifies for extra help.
The Drug List
Each Medicare drug plan has a list of prescription drugs that it covers, called a formulary, or drug list. Plans may cover both generic and brand-name prescription drugs. Most prescription drugs used by people with Medicare will be on a plan's drug list. To find out which drugs a plan covers, contact the plan or visit the plan's website. All Medicare drug plans must make sure that the people in their plan can get medically-necessary drugs to treat their conditions.
Prior Authorization
Medicare drug plans may have rules about prior authorization, quantity limits, and step therapy. Prior authorization means that the person and/or the doctor must contact the plan before certain prescriptions can be filled. The doctor may need to show that the drug is medically necessary for it to be covered. Quantity limits are limits on how many pills a person can get at a time. Step therapy is a type of prior authorization in which a person must try one or more similar, lower cost drugs before the plan will cover the drug the doctor prescribed.
If the doctor believes that one of these coverage rules should be waived, the person can ask for an exception. (If someone receives an exception, it means that a drug coverage rule does not apply in a particular case.)
For More Information
Having a variety of plans to choose from gives people with Medicare the chance to pick a plan that meets their unique needs. To help the person choose a plan that will provide the right coverage at the best price possible, you can
- visit http://www.medicare.gov to learn about Medicare prescription drug coverage, find and compare plans available in your area, and enroll in a plan.
- view or print copies of "Your Guide to Medicare Prescription Drug Coverage." (Under "Search Tools," select "Find a Medicare Publication.")
- call 1-800-Medicare (1-800-633-4227). TTY users should call 1-800-325-0778.
- call the State Health Insurance Assistance Program (SHIP) in your state for personalized help.
You can also find information in the "Medicare & You" handbook which is mailed out to Medicare enrollees in the fall. It includes detailed information about Medicare drug plans, including which plans are available in your area. Contact the plans you are interested in for more details.
