Yes, most Medicare Advantage plans cover prescriptions (Medicare Part D). Drug coverage attracts many people to Medicare Advantage, in addition to vision, dental, and hearing benefits. Medicare Advantage Prescription Drug (MAPD) plans typically cover certain formularies and in-network pharmacies. However, should you enroll in a plan that does not include coverage for the drugs you need, it may be wise to consider finding additional coverage elsewhere.
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The Importance of Getting Your Medications Covered
Prescription drug coverage is a critical aspect of healthcare in America, especially for seniors. Studies show a clear majority of Medicare-qualifying adults need reliable drug coverage. In fact, nearly 90% of older adults regularly take at least one prescription medication, and nearly 80% take at least two prescription drugs on a regular basis.
Affordable access to prescription medications can improve older Americans’ quality of life and, in many cases, prolong their lives. Older adults are more likely than younger people to need medication for multiple chronic conditions such as diabetes, high blood pressure, or arthritis. MAPD plans bundle essential medication coverage with other benefits.
How Does Medicare Advantage’s Prescription Drug Plan Work?
Original Medicare (Parts A and B) covers hospitalization and medical care. Medicare Advantage plans must offer the same coverage that Original Medicare does and often offers additional benefits beyond that. Many people pursue Medicare Advantage for vision, dental, and hearing services; however, most Medicare Advantage plans also include prescription drug benefits.
For those new to Medicare, the open enrollment period for MAPD plans begins three months before you turn 65, lasts for your birthday month, and ends three months after that. If you enroll in a MAPD plan during this once-only window, you can drop coverage and go back to Original Medicare at any time during the following 12 months. Otherwise, you must wait to make changes until the next annual open enrollment period.
Eligibility
You must already be enrolled in Original Medicare to be eligible for a MAPD plan. Additionally, you must live in the service area of your desired Medicare Advantage plan. Insurers may offer a variety of plans and can set their own cost for coverage depending on where you live. You may not hold supplemental Medicare coverage (Medigap) at the same time as a MAPD plan.
Coverage
Aside from the Part A and Part B benefits that all Medicare Advantage plans offer, MAPD plans cover prescription drugs under their formulary according to a tiered cost structure. The formulary typically includes a broad selection of prescription medications, proven against federal standards to be effective, safe, high-quality, and cost-effective.
Each drug in the formulary is assigned a corresponding cost, ranging from tier 1, which includes the lowest-cost medications and the most generic substitution options, to the fourth “specialty” tier, comprising the most exclusive, name-brand-only, and highest-cost drugs. However, keep in mind that each Medicare Advantage plan that includes drug coverage features a different formulary. If you’re looking to ensure that the specific drugs you need will be covered by the policy you are interested in, speak to the provider or a trusted insurance agent.
Limitations
Some types of Medicare Advantage plans participate in step therapy, using drugs covered by Part B. Step therapy requires beneficiaries to try a less expensive drug first to treat the same condition as a more costly drug in order for your MAPD to cover the prescription. If needed, your MAPD may still subsequently cover the more expensive medication.
In some cases, your doctor may submit a step therapy exception request for a specific medication. Some formulary restrictions also require doctors to submit a prior authorization request first. MAPD plans may include quantity limits for certain medications over a set period of time, such as 30 pills per month, with up to three refills.
Additional Benefits
Some MAPD plans may offer additional discounts for prescription medications you use regularly. Ask your insurer about potential discounts on frequent prescriptions. Additionally, you may be eligible for standalone pharmacy discount cards if you are a regular customer or for pharmaceutical assistance programs through the manufacturer of the drugs you use. Prescription discount cards sold by independent companies typically cannot be used with Medicare benefits.
Pharmacy Networks
Medicare Advantage prescription drug plans include their own network of participating pharmacies. You must make sure both your prescription drugs and your preferred pharmacy are in-network for MAPD plan coverage. Most Medicare Advantage plans will cover a portion, but not 100%, of mail-order pharmacy costs.
How Much Do Prescription Drugs Cost with Medicare Advantage?
Many Americans find themselves unable to afford the lifesaving prescription drugs they need, especially for common blood pressure and asthma medications; however, Medicare Advantage can help. MAPD plans can lower costs, though exact prices depend on the following factors:
- Monthly Premium: Your monthly premium is the fee you pay each month for the privilege of keeping your benefits and remaining enrolled in your plan. Many MAPD plans offer $0 or low-cost premiums, though you must continue to pay Part B premiums to keep coverage.
- Deductible: Your deductible is the amount you must reach through out-of-pocket expenses before Medicare begins to pay. While most MAPD plans include deductibles, they also implement an out-of-pocket maximum to help keep costs low for enrollees.
- Copayments and Coinsurance: Copays usually refer to the amount you pay for healthcare services before you meet your deductible, while coinsurance is generally required after your deductible is met, though sometimes they can coexist. Medicare pays for 80% of healthcare services (you pay 20% coinsurance) after the deductible.
- Formulary: As a beneficiary of Medicare Advantage, your prescription drug costs depend heavily on the rates of common prescription medications in the open market, including current availability and manufacturing concerns. Your rates may also fluctuate according to competition among drug manufacturers or pharmaceutical regulations.
- Pharmacy: MAPD plans include a network of pharmacies that accept Medicare Advantage drug benefits. If your medication is covered, but you choose an out-of-network pharmacy, filling your prescriptions may require some out-of-pocket costs.
- Coverage Gap: Coverage gaps occur when you reach a spending limit for prescriptions. Once you reach Medicare’s annual limit for covered drugs (this amount is $4,660 in 2023), your MAPD may temporarily limit its coverage. Your costs are capped at 25% in the coverage gap; however, nearly the full price of the medication counts toward your out-of-pocket expenses to help you out of the “donut hole.”
How To Get Medicare Advantage Drug Coverage
Most, but not all, Medicare Advantage plans cover prescription drugs. The most reliable means of finding MAPD plans is through the Medicare.gov online search portal. This interactive comparison tool enables you to locate and compare plans that do offer drug coverage in your area. Once you choose your plan, you may apply online, by phone, or by mail.
Alternatively, you may prefer to work with an independent insurance agent or Medicare consultant to help you find local Medicare Advantage prescription drug plans or call private insurers directly to inquire about Medicare Advantage benefits. Remember to take advantage of the initial open enrollment period since you may pay a penalty for waiting to enroll.
Alternatives to Medicare Advantage Prescription Drug Plans
If a Medicare Advantage prescription drug plan is not accessible or affordable for you, you may want to consider other options for drug coverage, such as:
- Medicare Part D: Part D plans are the prescription drug component usually associated with Original Medicare, however they are sometimes available to those with MA. Suppose your Part C plan does not include prescription coverage. In that case, you may consider enrolling in Part D. Keep in mind that, like Medicare Advantage, Part D plans are sold by private insurers, who apply a formulary to their coverage. Therefore, ensure that the plan you are considering offers coverage for the drugs you need.
- Private Health Insurance: Though most people are eligible for Medicare at 65, not everyone elects to fully enroll in Medicare if they can still receive prescription drug coverage outside of Medicare. This generally applies to those who are not yet retired and still receiving healthcare through their employer or COBRA.
All in All
Most Medicare Advantage plans cover prescription drugs in addition to providing other benefits such as vision, dental, and hearing services. You become eligible to enroll in an MAPD plan at the same time you qualify for initial Medicare benefits when you turn 65. You may enroll as soon as your Part B coverage begins or wait until the next Medicare Advantage open enrollment period.
MAPD plans offer the most comprehensive medical and prescription drug coverage for Medicare beneficiaries; however, you may need a less expensive alternative. Instead of purchasing an MAPD plan, you can add a standalone Part D plan to Original Medicare as soon as you become eligible for initial benefits.