Almost nine in 10 adults 65 years and older take at least one prescription medicine. With this in mind, it makes sense that seniors on Medicare need a prescription drug plan to help pay for their medications. Since 2006, Medicare has offered prescription drug coverage for all seniors on Medicare called “Part D.” Kupuna can choose between one of two ways to get Medicare prescription drug coverage. The first option is to join a Medicare Prescription Drug Plan (PDP) and the second is to join a Medicare Advantage Plan that includes prescription drug coverage.
A prescription drug plan is only as good as the medications it covers. In this article we take a look at what drugs are covered by Medicare Part D Plans. If you have specific health issues that are managed with prescription drugs, contact a Medicare Agent for help finding the right drug plan for you.
What Drugs are Covered by Medicare Part D?
Seniors have many individual Part D drug plans to choose from with different co-pays and premiums. All Medicare Part D Plans must cover a wide range of prescription drugs commonly taken by people on Medicare, including the majority of drugs in certain “protected classes.”*
*Medicare’s protected drug classes are anticonvulsants, antineoplastics, antidepressants, antiretrovirals, immunosuppressants, and antipsychotics.
Most Medicare Drug Plans and Medicare Advantage Plans with prescription drug coverage have a list of the drugs they cover, called a “formulary.” Every formulary includes both brand-name prescription drugs and their generic alternatives, which are considered copies of name-brand drugs. Each formulary must include at least two drug options in the categories and classes most commonly prescribed to seniors.
Many plans divide the drugs they cover into four levels called “tiers.” Each tier is associated with a specific out-of-pocket cost.
Tier 1 - Drugs in tier one usually come with the lowest copayment and include the most generic prescription drug options.
Tier 2 - The second tier has a medium copayment and includes preferred, brand-name prescription drugs.
Tier 3 – Drugs in the third tier come with an even higher copayment and include non-preferred, brand-name prescription drugs.
Specialty tier – Drugs in the specialty tier have the highest copayment and include very high-cost prescription drugs.
Choosing the right Medicare PDP
When evaluating different Medicare PDPs, you may come across an option where the formulary doesn’t list your exact prescription medication. In most cases, a similar drug will be available but it’s best to look into that before signing up. Plan members may also be able to ask for an exception if they or their medical provider believes that there is no drug on their plan’s formulary that will work for their health condition.
In almost all cases, seniors will want to use the drugs on their plan’s formulary – and in particular the generic versions - because it will save them money. Unless an exception is in place, plan members would pay full price for any prescription drug that is not on the formulary.
Drug formularies can change
Something important to keep in mind is that a Medicare drug plan is entitled to makes some changes to its formulary during the year as long as it follows Medicare guidelines. These guidelines stipulate that a drug list may be changed if new drugs are released, drug therapies change or new medical information becomes available. In addition, a Medicare Drug Plan may immediately drop a drug from their approved list if the Food and Drug Administration (FDA) deems them unsafe or if the drug’s manufacturer pulls them from the market. Some plans are also entitled to remove brand name drugs from their formularies and replace them with new generic drugs, or they are allowed to change the cost or coverage rules for brand name drugs once they add new generic drugs.
Find out which plans cover the drugs you need. Contact a PBC Agent for Help!
Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.
At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.