Medicare provides prescription drug coverage to all Medicare beneficiaries. If you choose not to enroll in a Medicare Prescription Drug Plan when you are initially eligible, and you do not have other credible prescription drug coverage or Extra Help, you may incur a late enrollment penalty. To obtain Medicare drug coverage, you need to join a plan offered by an insurance company or other private company approved by Medicare. The cost and coverage of medications can vary between each plan.
2 Ways To Get Drug Coverage
- Medicare Prescription Drug Plan (Part D): These plans, also known as “PDPs,” provide additional drug coverage for beneficiaries enrolled in Original Medicare, certain Medicare Cost Plans, specific Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
- Medicare Advantage Plan (Part C) or other Medicare health plan with prescription drug coverage: These plans, including HMOs or PPOs, offer comprehensive coverage that includes Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and prescription drug coverage (Part D). By enrolling in these plans, you receive all your Medicare benefits through a single plan. Medicare Advantage Plans that include prescription drug coverage are often referred to as “MA-PDs.” It’s important to note that to join a Medicare Advantage Plan, you must be enrolled in both Part A and Part B.
What Drug Plans Cover
Each Medicare Prescription Drug Plan maintains its own formulary, which is a list of drugs covered by the plan. These formularies typically assign drugs to different tiers, each with a different cost.
Drugs in lower tiers generally have lower out-of-pocket costs compared to drugs in higher tiers. However, if your prescribed medication falls into a higher tier and your healthcare provider believes that it is necessary for your treatment instead of an alternative drug on a lower tier, you or your provider can request an exception from your plan. This exception can allow you to obtain the higher-tier drug at a lower copayment, ensuring you have access to the medication you need.
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