Quick Facts
Medicare Health Plans.
The Three C’s: Coverage, Cost, and Convenience.
About Coverage
Medicare health plans provide at least the same level of doctor, hospital, and prescription
drug benefits that are available in Original Medicare (Parts A & B). Many Medicare plans
provide additional benefits that go beyond Original Medicare.
For example, many plans provide: |
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A cap that limits what you pay out of pocket each year for doctor and hospital services |
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Additional preventive care |
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Dental and/or vision benefits |
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Other benefits like limited transportation to help you get to and from medical appointments |
Different Medicare health plans have different lists of drugs that they cover.
The list of drugs and other information about what the health plan covers is called the formulary.
Medicare requires that all plans provide coverage for almost all classes of drugs.
If the plan does not have a certain drug on its formulary, it must include another drug in the same
class of drugs that may work for you.
If the alternative drug does not work for you, you may request an exception to have your drug
covered by your plan’s formulary. If you are interested, ask the plans you are considering about the
process you must follow in order to get an exception to the formulary.
Some Medicare health plans may have other requirements.
They may include:
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Quantity limits: This limits the number of pills (or drops) that you may get at one time. |
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Prior authorization: This requires you to get approval from the plan before you get the drug. |
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Step therapy: This requires you to try a plan's preferred brand-name drug first, before using a non-preferred
brand-name drug. Or, it requires that you show that you have already tried the preferred brand-name drug and that it did not work for you or that you had an adverse reaction to it. |
Medicare does not pay for some types of drugs.
These are excluded drugs. For example, drugs you get without a prescription, vitamins and mineral
supplements, drugs used for weight loss, and some tranquilizers (known as benzodiazepines) are
excluded drugs. However, some Medicare health plans provide coverage for some excluded drugs as
an extra benefit for their enrollees. Also, if you receive help from Medicaid, your state Medicaid program MAY
cover some of these drugs.
Many Medicare health plans do not provide coverage in the coverage gap, but some plans do.
You are in the coverage gap when the total cost of your prescription drugs in 2008 goes above $2,510.
The coverage gap continues until your total out of pocket costs in 2008 reach $4,050.
About Cost
Medicare pays most of the cost of your prescription drugs, except in the coverage gap. But you pay a portion.
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When you join a Medicare health plan, you will receive a monthly statement that will tell you how
much you have spent on prescription drugs and on other health care services. |
There are four ways that a Medicare health plan may ask you to pay your share:
Premiums, deductibles, and copays or coinsurance will vary from plan to plan.
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You will generally pay one monthly premium to your Medicare health plan that covers your portion
of the costs for your Medicare doctor, hospital, and prescription drug coverage. |
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Many Medicare health plans limit the amount you must pay out of pocket for doctor and hospital
services each year. |
If you have limited income and assets:
You may qualify for extra help covering your prescription drugs or other Medicare-related costs.
See our Money Saving Tips section for more information.
Medicare health plans require that you use a pharmacy in their pharmacy network except
under certain circumstances such as emergencies.
Medicare health plans have a list of pharmacies known as a pharmacy network. Some networks are
broad. Others are more limited. In order for your plan to pay for your prescriptions, you generally
must go to a pharmacy in the plan’s network.
About Convenience
For HMO, PPO, and Cost Plans:
Each of these kinds of Medicare health plans has a list of doctors, hospitals, and other
professionals. This is called a network. Some networks are more limited. Others are broad. With some
plans, if you go to a provider in the plan’s network, you will generally pay less. In most HMOs, in
most cases, however, you are covered only when you use doctors, specialists, and hospitals on the
plan’s list, except in an emergency.
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Find out if your doctor(s) and hospital(s) are in the plan’s network. If not, you may want to
consider changing doctors or hospitals to save money. |
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Any Medicare Advantage or Medicare Cost Plan that you are considering will be able to tell you
whether your preferred doctor(s) and hospital(s) are in the plan's network. |
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You may also want to check with your doctor(s) and hospital(s) to determine if they are currently
accepting patients from the plan you are considering. Some providers limit the number of patients
they see from some health plans. |
For Medicare Advantage Private Fee-for-Service (PFFS) Plans:
Another kind of health plan, known as Private Fee-for-Service Plans, may also be available in your
area. These plans allow you to go to any Medicare-approved doctor or hospital that will accept your
plan’s terms and conditions of payment.
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Before enrolling in a PFFS plan, you will want to confirm with the
doctor(s) and hospital(s) that you expect to use that they will accept the
plan’s terms and conditions of payment. If your doctor or hospital does
not agree to accept the Private-Fee-for-Service Plan’s payment terms and
conditions, they may NOT provide health care services to you, except in
emergencies. Providers can find the terms and conditions on the plan’s
website. |
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Doctors and hospitals may, on a patient-by-patient and visit-by-visit basis,
decide whether to accept your coverage. You must inform them BEFORE
receiving services that you are a PFFS plan member so they can decide
whether to accept that plan’s terms and conditions. |
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Some doctors and hospitals that accept Original Medicare may not accept
your PFFS coverage. |
Some Medicare health plans may have additional requirements.
For example, some plans may require prior authorization for certain health care services, such
as a non-emergency hospital stay.
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If you travel a lot or live in more than one place during the year, talk
with the health plan to make sure it can provide your medical and
pharmacy services in the communities where you are likely to be. |
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