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Prescription drugs can cost a lot of money, especially if you need several different medications. Or, you might have a health condition that requires expensive prescription drugs to manage or treat the illness. Read some tips about getting affordable prescription drug coverage.
Doesn’t Medicare cover my prescription drugs?
For starters, you need to know that Original Medicare (Part A and Part B) doesn’t cover most medications you take at home. It does cover prescription drugs in limited situations. Part A usually covers medications used to in your treatment as a hospital inpatient. Part B may cover prescription drugs given to you in an outpatient setting, usually ones you wouldn’t take on your own.
How can I get Medicare prescription drug coverage?
You can get prescription drug coverage under Medicare Part D. This program lets private insurance companies contract with Medicare to provide prescription drug coverage.
There are two ways to get Medicare prescription drug coverage.
- You can sign up for a Medicare Part D Prescription Drug Plan to work alongside your Part A and/or Part B coverage.
- You can enroll in a Medicare Advantage Prescription Drug plan. These plans include your Medicare Part A and B coverage as well, only though the plan instead of through the government directly. Not every Medicare Advantage plan includes prescription drug coverage, but most do. Read more about Medicare Advantage.
Whichever type of Medicare Prescription Drug Plan you sign up for, you might want to make sure it covers your prescriptions. Each plan maintains its own formulary, which is a list of prescription drugs it covers. Formularies are divided into “tiers” – the lowest tier generally has less expensive, generic drugs, while the highest tier generally has more expensive, brand-name drugs.
Even if you choose a plan that covers your medications, that might change. Every fall, your plan will send you an Annual Notice of Changes. Check to see if your medications have been dropped or if the costs have changed.
A plan’s formulary might change any time of year, not just at year’s end. You will receive notice from your plan when necessary.
What if I have a Medicare Prescription Drug Plan, but my prescription drugs are still too expensive?
You might have some options if your medications are too expensive.
- Ask your doctor if there’s another medication you can use instead. For example, generic drugs are generally cheaper than their brand-name equivalents.
- You might be able to ask for a “tiering exception” if you need an expensive prescription drug (for example, a brand-name “higher tier” drug). If your doctor determines that there are no lower-tier substitutions that would adequately treat your condition, you or your doctor can file a Medicare appeal to see if you can pay less for that medication.
- You also have the right to file a Medicare appeal if you think your Medicare Prescription Drug Plan should cover a particular medication.
- If you have a low income or no income, you might be eligible for the Medicare Extra Help program. If you qualify for this program, you’ll pay no more than $3.40 for any generic drug and $8.50 for any brand-name prescription drug and for beneficiaries who qualifies for LIS Level 4 will pay 15% of their drug cost in 2019.
- If you don’t qualify for Extra Help, you might be eligible for assistance through Medicaid or the State Health Insurance Assistance Program (SHIP). Both these agencies have offices in every state.
What if I don’t have a low income, but my prescription drug expenses are high?
You might want to know about the Medicare Part D “donut hole” and catastrophic coverage.
- If you and your plan spend a certain amount within a year ($3,820 in 2019), you enter a coverage gap also known as the donut hole. This gap is closing year by year because of the Affordable Care Act.
- In 2019, you’ll pay a maximum of 25% of the cost of brand-name prescription drugs, and 37% of the cost of generic drugs.
- If your out-of-pocket spending rises to $5100 within a year (in 2019), you leave the coverage gap and only pay a small amount for each medication for the rest of the year. This amount can change from year to year.