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Quick Facts
Stand-Alone Drug Plans.
The Three C’s: Coverage, Cost, and Convenience.
About Coverage
Different Medicare drug plans have different lists of drugs that they cover.
The list of drugs and other information about what the stand-alone drug plan covers is called the formulary.
Medicare requires that all Medicare drug plans provide coverage for almost all classes of drugs.
If the plan does not have a certain drug on its formulary, it must include on its formulary 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. If you are interested, ask the plans you are considering about the process you must follow to get an exception to the formulary.
Some Medicare drug 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 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, 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.
Most Medicare drug plans will not provide coverage for these excluded drugs. However, some prescription drug plans do cover 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 prescription drug 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 exceeds $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 (see above). But you pay a portion.
When you join a stand-alone drug plan, you will receive a monthly statement that will tell you how much you have spent on prescription drugs. There are four ways that Medicare drug plans may ask you to pay your share:
Premiums, deductibles, and copays or coinsurance will vary from plan to plan.
If you have limited income or assets:
You may qualify for extra help paying for your prescription drugs or other Medicare-related costs. See our Money Saving Tips section for more information.
Most stand-alone drug plans divide the drugs on the formulary into cost-sharing tiers.
The tier your drug falls into will determine how much you pay. Using generic or preferred brand-name drugs will help reduce your costs. In many plans, prescription drugs are grouped into the following tiers:
Most Medicare drug plans require that you use a pharmacy in their pharmacy network.
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Most Medicare drug plans have a list of pharmacies that you can use to get your prescriptions
filled. This list is called a pharmacy network. Some networks are more limited. Others are broad.
In order for your plan to pay for your prescription, you generally must go to a pharmacy in the
plan's network. |
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If you travel a lot or live in more than one place during the year, you may want to consider a stand-alone drug plan that offers national coverage. |
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About Convenience
If you have a chronic condition that requires you to use the same drug(s) over a long period of
time, you may be able to save money by getting a longer supply of your prescription (e.g., 90 days)
through your pharmacy or through mail order.
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