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Your Medicare Plan Doesn't Cover Prescription Drug Costs? Here's What You Can Do

By Michael Howard
When it comes to prescription drugs, Medicare offers very limited coverage. Learn how you can make your medications more affordable.

Nearly 70 percent of American adults between the ages of 40 and 79 use at least one prescription drug, and more than 22 percent use at least five, according to the Centers for Disease Control and Prevention. Under Original Medicare (Parts A and B), prescription drug coverage is restricted to a limited number of outpatient drugs, such as those that have to be professionally injected or infused. That means millions of American seniors have to find other ways to cover their medication costs. We outline three of them below.

Enroll in a Medicare Part D Plan

According to the official U.S. government website for Medicare, Medicare Part D is a form of insurance that provides prescription drug coverage to beneficiaries of Original Medicare and selected Medicare Cost Plans, Private Fee-for-Service Plans, and Medical Savings Account Plans. You must have either Medicare Part A or Medicare Part B in order to qualify for a Medicare Part D plan.

The official U.S. government website for Medicare also reports that all Medicare Part D plans must offer coverage for a wide range of prescription medications that people on Medicare commonly take. This includes most medications that are in selected protected classes, such as those used to treat cancer and HIV/AIDS. 

“Every Part D plan has a different formulary (list of covered prescriptions), and that formulary can change each year,” Matthew Claassen, CEO of Medigap Seminars Insurance Agency, tells WebMD Connect to Care.

Additionally, each plan’s formulary will typically be divided into tiers, with the lower tiers containing relatively cheaper drugs and the higher tiers containing more expensive ones. 

“Some Part D plans are designed for people with few or no prescriptions and have a formulary that emphasizes lower-tiered drugs. Some are designed for people who have very expensive prescriptions,” Claassen explains. 

In the latter case, Claassen notes, the plans “are designed to get a person into ‘catastrophic coverage’ fast, so that Medicare pays 95 percent of the prescription costs.”

Opt for Medicare Advantage

Also known as Medicare Part C, Medicare Advantage is a type of private insurance that functions as an alternative to Original Medicare. It offers all of the benefits included in Medicare Parts A and B. Additionally, many Medicare Advantage plans cover things like dental, vision, hearing, and prescription drugs. They also place limits on yearly out-of-pocket costs.

To sign up for a Medicare Advantage plan, you must be Medicare-eligible or already enrolled Medicare Parts A and B. You also need to live in a Medicare Advantage service area. 

There are numerous Medicare Advantage plans to choose from. You can use the official U.S.government website for Medicare to compare the plans available to you. While shopping, pay close attention to premiums, deductibles, and coinsurance. Each of these factors will affect your overall drug coverage costs. You can also use the official U.S. government website for Medicare to learn how the various plans in your area have been rated.

Access Public and Private Programs

A number of federal, state, and private programs exist to help people make their prescription drugs more affordable. Medicare recommends consulting the National Patient Advocate Foundation or the National Organization for Rare Disorders for information about programs available to you.

The Social Security Administration (SSA) also offers the Extra Help program, which assists low-income Medicare beneficiaries with their prescription drug plan fees. You can check eligibility qualifications and apply for Extra Help on the official government SSA website. 

You can also check to see whether you qualify for State Pharmaceutical Assistance Programs (SPAPs) or Manufacturer’s Pharmaceutical Assistance Programs. To find out what these programs can do for you, visit the official U.S. government website for Medicare.

Get started now

Interested in learning more about Medicare, Medigap, and Medicare Advantage plans? WebMD Connect to Care Advisors may be able to help.