Southwest public affairs officer for the U.S. Centers for Medicare and Medicaid Services
Medicare offers prescription drug coverage to everyone with Medicare.
It’s a good deal. Medicare subsidizes the outpatient drug benefit, generally paying about 75 percent of the program’s costs. Unless you already have comparable drug coverage through another source, you should consider getting it when you sign up for Medicare’s health care coverage at 65.
There are two ways to get drug coverage. If you’re in Medicare’s traditional fee-for-service program, you can purchase a “stand-alone” drug plan from an insurance company. Or, if you decide to buy a private Medicare Advantage health plan, you can choose one that includes drug coverage.
To find the “stand-alone” drug plans and the Medicare Advantage health plans with drug coverage available in your area, visit Medicare’s “plan finder” at www.medicare.gov/find-a-plan. You can also call Texas’ Health Information Counseling and Advocacy Program for help at 1-800-252-9240.
You’ll see there are significant differences in premiums and deductibles, in the co-payments the plans charge, in the particular drugs they cover and in the pharmacies they use. That’s why it’s important to look at your prescriptions and individual circumstances when comparing plans.
Ask yourself: Which plans cover the drugs I take? Which plan gives me the best overall price on all my drugs? Which plans allow me to use the pharmacy I want? Which plans let me get drugs through the mail? What are the plans’ quality ratings, such as for customer service?
You’ll discover that many plans place drugs into different “tiers.” The higher the tier, the greater your share of the cost will usually be. If you find that a prescription of yours is in a higher tier, you may want to ask your doctor whether there’s a drug in a lower tier that would work as well.
You may also encounter plans that follow “step therapy.” That means you must first try a less-expensive drug that’s been proven effective for most people with your condition before you can move up to a costlier drug. However, your doctor can request an exception if the costlier drug is medically necessary.
Medicare drug coverage is just like other kinds of insurance – you buy it to protect yourself if and when you need it. Even if you’re not on any prescriptions now, enrolling in a drug plan with a low premium guarantees you’ll have coverage should your health decline and you require medication.
After you pick a plan that meets your needs, call the company offering it and ask how to join. You may be able to join online, by phone or by paper application. Don’t be alarmed when you’re asked to provide the number on your Medicare card during the enrollment process. In this case, it’s OK.
The plan that’s best for you this year may not be the best next year. If so, you can switch to another plan between Oct. 15 and Dec. 7 each year. Indeed, it’s smart to check all your options every fall to make sure you have the plan that best fits your needs and pocketbook. Your new coverage then begins on Jan. 1.
If you’re having difficulty affording medications, you may qualify for the government’s “extra help” program. Your annual income can’t be more than $18,090 if you’re single or $24,360 if you’re married. Also, your resources can’t exceed $13,820 if you’re single or $27,600 if you’re married.
Generally, you’ll pay no more than $3.30 for each generic drug and $8.25 for each brand-name prescription in 2017. Thirty-five percent of Texans with a Medicare drug plan get extra help. To apply, visit the Social Security website, at www.socialsecurity.gov/i1020, or call Social Security at 1-800-772-1213.
People with Medicare have saved hundreds or even thousands of dollars each year thanks to their drug coverage. Be sure to make the most of yours.
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