How to Review Your Medicare Plan’s Prescription Coverage

Signing up for Medicare can be a daunting task, but once you’re in, your work isn’t done yet. It’s important to review your plan every year during open enrollment — from Oct. 15 to Dec. 7 each year — because rules and coverages change from one year to the next. This is true for your prescription drug coverage as well as your basic medical coverage.

According to the U.S. Centers for Medicare and Medicaid Services, most Medicare prescription drug plans, called Part D, charge a monthly premium that varies by plan. You pay this in addition to the Medicare Part B premium, which covers medical costs. If you join a Medicare Advantage plan, also known as Part C, or a Medicare Cost plan that includes Medicare prescription drug coverage, the plan’s monthly premium may include an amount for drug coverage.

[See: 15 Things Millennials Should Know About Open Enrollment.]

CMS has made some changes to 2019 plans. According to eHealth’s website, some of these changes include:

— Allow Medicare Prescription Drug Plans, or PDPs, to restrict access to opioids and other prescription drugs for beneficiaries who are at risk of addiction. Plans won’t restrict access to pain medications such as opioids for some patients, however, such as cancer and hospice patients.

— Lower costs by changing certain requirements about cost sharing for generic drugs.

— Reduce waste by lowering the quantity of prescription drugs that PDPs need to supply at one time. For example, instead of providing a 90-day supply, it might only need to provide a 30-day supply.

— Increase flexibility of formulary changes. For example, a PDP can substitute a generic drug for a brand-name drug in some cases.

Every year, existing Part D and Part C plans review their list of covered drugs, called formularies, and pricing structures, called tiers. And new plans enter the market with different formularies and different tiers. The changes these bring can be significant in terms of what you get and what you pay.

Tier 1 drugs are typically generics and require the lowest copayment. A tier 2 drug may be a brand-name prescription drug with a higher copayment. Tier 3 is the most expensive drug tier and may include unique and nonpreferred brand-name prescription drugs. “We have found that, with new regulations under CMS, a tier 1 generic drug could be moved to a tier 2 or tier 3,” says Tatiana Fassieux, a consultant with California Health Advocates, a Medicare advocacy organization. “Your own (prescription) could move between tiers without your knowing it, unless you are on top of it.”

[Read: Open Enrollment 2019 — What You Should Know.]

That’s why members need to check their plan’s formulary every year, and if they see a change in pricing, talk with their doctor. “People are often complacent about speaking to their doctors about scripts they are taking,” Fassieux says. “Older adults often keep taking the same meds over and over without having that conversation with their doctor. They need to have an in-depth discussion to find out if they can drop some of their meds or switch some to a less expensive kind.”

Rules for prior authorization — meaning your insurance carrier must approve any changes to your medications — may also change, says Andrew Shea, vice president of Medicare Products at, “and there are not always obvious reasons why.” And plans now work more with preferred pharmacies, meaning you get a better price at, say, Walgreens than you do at CVS. “Pharmacy networks weren’t as important five or six years ago as they are today,” Shea says. “If you are a Walgreens person, some plans might be OK, but at others you have to pay quite a bit more.”

When reviewing your coverage, it is important to have a full list of all your prescription drugs and dosages to make sure your medications are on the formulary, and choose more than one pharmacy to compare costs, says Fred Riccardi, vice president of client services for the Medicare Rights Center. “And look at not only the monthly premium, but also how much the script costs on a monthly basis and if there are any additional restrictions, like step therapy or quantity limits,” he advises.

When reviewing drug coverage, keep in mind that this is only one part of your total benefits package. “A mistake people make is focusing too much on one benefit,” Shea says. The plan may not use your preferred pharmacy, for instance. “But when you look at the totality of the plan, the primary doctor network, the medical and hospital benefits, if you don’t take that many drugs, it may not matter. It may still be the less expensive plan.”

[Read: 7 Factors to Consider When Shopping for Health Insurance.]

If all of this seems overwhelming, rest assured: Help is available. “You can do it yourself — it’s just very difficult to do it in a way you feel confident about,” Shea says. “I am of the opinion that it makes no sense to do that without the help of an independent advisor who understands your plan and other plans in your market and how they are changing and can give you a candid assessment. The most impactful changes aren’t always super obvious. If the premium goes up a lot, you can find a less expensive plan, but some of the subtleties are important, and a broker can be helpful.”

You can also get free, personalized health insurance counseling by calling your State Health Insurance Assistance Program. Visit or call 1-800-MEDICARE to get the local phone number.

The most important thing to remember is to do something. “Our boots-on-the-ground experience is that people are complacent,” Fassieux says. “We say, don’t be.”

More from U.S. News

Open Enrollment 2019: What You Should Know

15 Things Millennials Should Know About Open Enrollment

7 Factors to Consider When Shopping for Health Insurance

How to Review Your Medicare Plan’s Prescription Coverage originally appeared on

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