Prescription Drug Plans

You have two ways to get prescription drug coverage:
1. Enroll in a separate Medicare Prescription Drug Plan to supplement your Original Medicare plan.
2. Enroll in a Medicare Advantage Plan (Medicare Part C) that bundles Original Medicare (Part A and B) with prescription drug coverage.

Some, but not most. Medicare Part B covers a limited number of outpatient prescription drugs that you’d receive at a doctor’s office or hospital outpatient setting. Typically, the drugs covered are the ones you wouldn’t give to yourself, like those requiring durable medical equipment or injectable osteoporosis drugs.

Your standard, self-administered drugs that you’d get at a pharmacy would not be covered under Original Medicare.

All Prescription Drug Plans must cover a wide range of drugs. You can find out which drugs are covered by requesting to see the insurance plan’s drug list – commonly called a “formulary.” Check the insurance plan’s formulary to make sure the plan covers the specific drugs you need before enrolling.

All Medicare plans generally must cover at least two drugs per prescription drug category, but the plans can choose which specific drugs they cover. Also, drug plans are required to cover almost all drugs within the following protected classes:

• Antipsychotics
• Antidepressants
• Anticonvulsants
• Cancer drugs
• HIV/AIDS
• Immunosuppressants

That will vary depending on the plan you choose. You will still have to pay a premium, deductible, copayments or coinsurance throughout the year, like any insurance plan. However, your actual drug coverage cost will depend on which type of drugs you take – name-brand or generic – and at which tier the drug is placed. The higher the tier, the higher the copayment for the drugs.

Most Medicare prescription drug plans have a coverage gap, sometimes called the “donut hole.” This means there is a temporary limit on what the drug plan will cover for drugs. This happens once you and your plan spend $4,430 on drugs (including the deductible).¹ During this time, you’ll generally pay 25% of the cost for your prescriptions until you reach the Catastrophic Coverage level (see below).

If your out-of-pocket spending reaches $7,050 on prescription drugs in a plan year, you’ll automatically get “catastrophic coverage.” This means if you spend this amount, then you’ll only have to pay 5% of the cost for covered drugs for the rest of the year.

Extra Help is a program that assists people with limited income and resources to pay for the costs of their prescription drug coverage. These costs may include premiums, deductibles and coinsurance.

If you qualify for Extra Help or want to see if you do, then speak to a licensed insurance agent to find out.