What Medicare Part D Drug Plans Cover
Each plan that offers prescription drug coverage through Medicare Part D must give at least a standard level of coverage set by Medicare. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different "tiers" on their formularies. (A formulary is a listing of all of the drugs/medications that a particular plan has available to their members. All Medicare Part D Plans must have two drugs available in each category.
Most Medicare drug plans (Medicare Prescription Drug Plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer. The formulary might not include your specific drug. However, in most cases, a similar drug should be available. If you or your prescriber (your doctor or other health care provider who’s legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception. A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.
Plans offering Medicare prescription drug coverage under Part D may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards. For other changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:
For 2019 and beyond, drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re taking these drugs, you’ll get information about the specific changes made to generic drug coverage afterwards. You may need to change the drug you use or pay more for it. You can also ask for an exception. Generally, using drugs on your plan’s formulary will save you money. If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generic drugs instead of brand-name drugs may save you money.
The Food and Drug Administration (FDA) says generic drugs are copies of brand-name drugs and are the same as those brand-name drugs in:
Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you. Talk to your doctor or other prescriber about your generic drug coverage. To lower costs, many plans offering prescription drug coverage place drugs into five different “Tiers” on their formularies. Each plan can divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier. Here's an example of a Medicare drug plan's tiers (your plan’s tiers may be different):
************A Generic Specialty Drug Tier is expected to be available on 1/1/2021.
In some cases, if your drug is in a higher (more expensive) tier and your prescriber .thinks you need that drug instead of a similar drug on a lower tier, you can file an exception and ask your plan for a lower copayment. Remember, this is only an example—your drug plan's tiers may be different.
If you're in a Medicare drug plan and take medications for different medical conditions, you may be eligible for a free Medication Therapy Management (MTM) program. This program helps you and your doctor make sure that your medications are working to improve your health.
Through the MTM You'll Get:
A Pharmacist or Other Health Professional Will Talk With You About:
It’s a good idea to schedule your medication review before your yearly wellness visit, so you can talk to your doctor about your action plan and medication list.
Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, take your medication list with you if you go to the hospital or emergency room.
If you take many medications for more than one chronic health condition, contact your drug plan to see if you're eligible for a Medication Therapy Management program.
Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. In the past, some prescription drug plans weren’t making sure that some customers still wanted or needed a prescription drug and this created waste and unnecessary additional costs for people with Medicare and Medicare Prescription Drug Coverage, which is also referred to as Medicare Part D).
Now, plans have to get your approval to deliver a prescription (new or refill) unless you ask for the refill or request the new prescription. Some plans may ask you for your approval every year so that they can send you all new prescriptions without asking you before each delivery. Other plans may ask you before each delivery. This policy won’t affect refill reminder programs where you go in person to pick up the prescription, and it won’t apply to long-term care pharmacies that give out and deliver prescription drugs. Giving your approval may be a change for you if you've always used mail-order in the past and haven't had the opportunity to confirm that you still need refills.
Be sure to give your pharmacy the best way to reach you, so you don't miss the refill confirmation call or other communication.
Contact your plan if you get any unwanted prescription drugs through an automated delivery program.
You may be eligible for a refund for the amount you were charged. If you aren’t able to resolve the issue with the plan or wish to file a complaint, call 1-800-MEDICARE (1-800-633-4227).
If you have both Medicare and Medicaid or qualify for Extra Help, also bring with you any proof of your enrollment in Medicaid or proof that you do qualify for extra help.
Medicare drug plans have contracts with "network pharmacies." These pharmacies have agreed to provide members of certain Medicare plans with services and supplies at a discounted price. In some Medicare plans, your prescriptions are only covered if you get them filled at network pharmacies.
Along with retail pharmacies, your plan’s network might include preferred pharmacies, a mail-order program, or an option for retail pharmacies to supply a 2- or 3-month supply.
Filling a Prescription Without Your New Plan Card
If you go to the pharmacy before your drug plan card arrives, you can use any of these as proof of your drug plan enrollment:
If you don't have any of these items, your pharmacist may be able to get your drug plan information. You'll need to provide your Medicare Number or the last 4 digits of your Social Security Number.
If your pharmacist can't get your drug plan information, you may have to pay some out-of-pocket costs for your prescriptions. If you do, save your receipts and contact your plan to get your money back.