Prescription Drug Plans (PDPs)

Medicare drug coverage is an optional benefit assisting with prescription costs, available to all Medicare beneficiaries.

It's recommended to enroll early to prevent lasting penalties if you decide to join later without alternative credible coverage.

To obtain this coverage, you must join a Medicare-approved plan, with each plan varying in costs and specific drugs covered. Evaluating these details helps in choosing the most suitable plan for your needs.

2 Ways to get Medicare Drug Coverage

  1. Medicare Drug Plans: These plans add prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Private Fee-for-Service plans, and Medical Savings Account plans. To enroll in a separate Medicare drug plan, you must have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance).

  2. Medicare Advantage Plans (Part C) or Other Medicare Health Plans with Drug Coverage: These plans provide all-in-one coverage, including Part A, Part B, and drug coverage. Note that having Part A and Part B is a prerequisite for joining a Medicare Advantage Plan, and not all of these plans include drug coverage.

Formularies

Most Medicare drug plans, including Medicare Advantage Plans with prescription drug coverage, have their own drug list known as a formulary.

This list covers both brand-name and generic drugs, with at least 2 drugs in the most commonly prescribed categories. While each plan must generally cover at least 2 drugs per category, they have the flexibility to choose which drugs they offer.

If your specific drug is not on the formulary, a similar alternative is usually available. You can request an exception if you, or your prescriber, believe none of the drugs on the formulary are suitable for your condition.

Additionally, Medicare drug plans can make changes to their drug list during the year based on evolving medical information and the release of new drugs.

Generic Drugs

The Food and Drug Administration (FDA) explains that generic drugs are like brand-name drugs in several important ways:

  • Dosage form: They look the same.
  • Safety: They are equally safe.
  • Strength: They have the same amount of medicine.
  • Route of administration: They are taken the same way.
  • Quality: They meet the same quality standards.
  • Performance characteristics: They work the same.
  • Intended use: They are used for the same purpose.

Generic drugs use the same ingredients as brand-name drugs, and the makers of generic drugs must prove to the FDA that their product works just as well. While an exact match might not always be available, there could be another generic drug that is equally effective. It's a good idea to discuss your generic drug options with your doctor or whoever prescribes your medication.

Tiers

To save on costs, prescription drug coverage plans categorize drugs into different "tiers" on their formularies. Each tier has a different cost, with lower tiers being less expensive than higher ones. For example:

  • Tier 1: Lowest copayment for most generic drugs.
  • Tier 2: Medium copayment for preferred, brand-name drugs.
  • Tier 3: Higher copayment for non-preferred, brand-name drugs.
  • Specialty tier: Highest copayment for very high-cost prescription drugs.

If your prescribed drug is in a higher tier, you or your prescriber can request an exception for a lower cost. Plans can change formularies at any time, and you may be notified of any changes affecting your medications.

Medicare drug coverage includes drugs for opioid use disorders, like buprenorphine, and also covers pain medications like methadone. However, Medicare Part A covers methadone for opioid use disorder as a hospital inpatient, and Part B covers methadone through an opioid treatment program.

Contact your plan or visit its website for the current formulary.

Part D Vaccine Coverage

Except for vaccines covered under Medicare Part B (Medical Insurance), Medicare drug plans must cover all commercially available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

Prior Authorization

You and/or your prescriber must contact your plan before you can fill certain prescriptions. Your prescriber may need to confirm the medical necessity for plan coverage. Plans might use prior authorization, covering a drug for some approved conditions but not others. In such cases, alternative drugs for the unapproved conditions are usually available on the plan's list of covered medications.

Quantity Limits

For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain period of time.

For example, most people prescribed heartburn medication take 1 tablet per day for 4 weeks. Therefore, a plan may cover only an initial one month supply of the heartburn medication.

If your prescriber believes that, because of your medical condition, a quantity limit isn’t medically appropriate (for example, your doctor believes you need a higher dosage of 2 tablets per day), you or your prescriber can contact the plan to ask for an  exception