How to Get Prescription Drug Coverage

How to Get Prescription Drug Coverage

Help with the puzzle

By Ashley Lipman 


If you’re in the market for new healthcare policy, one aspect you must pay
special attention to is prescription drug coverage. Whether you have private
insurance or Medicare, it’s essential to understand what medications are
covered and how much you’re expected to pay.


Trying to understand the nuances of health insurance can be daunting, so
we’ve put together this quick guide. Here we’ll go over what to look for before
making any decision and how to get drug coverage through Medicare or a private

What to Look for in Prescription Drug Coverage

While most health insurance plans come with prescription drug coverage, not
all cover all medications. How much you have to pay for medicine also varies by
program and depends on the drug.

When considering your options, make sure that you review the list of drugs
covered by the plan, known as the formulary. These formularies have ‘tiers’
that are groups of drugs that are classified
by price
. Your co-payment will depend on which tier a specific medication
is a part of.


Not all plans have the same tier system, but they generally work like this:


Tier 1 – These are the least expensive
drugs available on the plan and are typically limited to generic.

Tier 2 – Brand name drugs that the
insurer has designated as ‘preferred.’

Tier 3 – These come at a higher price out
of pocket. They’re non-preferred and expensive brand-name medications.

Tier 4 – The highest-priced drugs
typically used to treat rare conditions.


You can typically find a plan’s formulary on the insurer’s website. If you
can’t find the information online, call and ask for the insurer to send you a

Avoid unexpected costs by doing the research when you’re shopping for
coverage. Make sure that any prescriptions that you’re already taking are
covered. You also want to pay attention to whether your medications will be
covered by a co-pay or if you have to fulfill your annual deductible


Everyone who has Medicare can opt-in for the benefit of prescription drug
coverage. Remember that if you don’t sign up for Medicare Drug Coverage
at first, it’s likely that you’ll have to pay a late enrollment penalty when
you decide to join in the future.


You can avoid this fine if you have another creditable prescription or if
you get Extra Help. You automatically qualify for Extra Help if you have both
Medicare and Medicate, you’re in a Medicare Savings Programs, or if you get
Supplemental Security Income (SSI) benefits.


There are two options available; a Medicare Prescription Drug Plan (Part D)
or a Medicare Advantage Plan (Part C).


The first option, Medicare Prescription Drug Plan (Part D), is also often
called a PDP. It adds drug coverage to Original Medicare, Cost Plans, Private
Fee-for-Service (PFFS) Plans, and Medicare Savings Account (MSA) Plans.


Part D can be purchased in conjunction with a Medicare Supplement Plan or as
a standalone plan. They have a monthly premium in addition to what you already
pay. That said, this type of prescription drug plan is smart to manage the
costs of medication that you’re already taking.


If you’re entitled to Part A or enrolled in Part B of Original Medicare,
you’re eligible for a Part D plan. Your effective date and premium will depend
on when you enroll.

Medicare Advantage Plan 

You can also get drug coverage if you have a Medicare Advantage Plan (Part
C). Also referred to as MA-PDs, these plans offer you Hospital Insurance (Part
A), Medical Insurance (Part B), and cover prescription drugs. You have to have
Part A and B to join any Medicare Advantage Plan.

Additional Considerations

Before you decide on anything, there are a few additional considerations.
You may be eligible for other types of insurance through the following:


The Department of Veteran Affairs (VA)

The Indian Health Service

Medicare Supplement Insurance

Your employment

Union membership

Speak to your benefits administrator or plan provider before you make any
changes in your current policy or decide to enroll in a Medicare
prescription drug

Private Insurance

Most private health insurance plans pay a portion of your
drug costs. If you already have a policy, but your medications are not included
in the plan’s formulary, you can purchase a stand alone prescription drug plan.
The cost of these policies vary.


When you’re in the market for standalone drug coverage, be
wary. Some companies provide discounts on medication but aren’t exactly
insurance plans.

The Verdict

Before you sign up for any plan, make sure that you won’t be forced to pay high out-of-pocket costs for your prescriptions. Just because you have coverage doesn’t mean that your insurance pays 100% of your expenses. You can save money by conducting thorough research before settling on any policy.


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Have a Healthy Day!,


Rod Stone
Author, Publisher and Founder of r Healthy Living Solutions, LLC,  Supplier of Healthy Living information and products to improve your life.

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