Prescription Coverage for Medicare

If you want Medicare to help pay for prescriptions that you pick up at your local pharmacy or have delivered to you, Original Medicare alone isn’t going to provide adequate coverage. For the majority of your prescription needs, you’ll need to add a Part D prescription drug plan to Original Medicare (Parts A and B), or you’ll need to switch to a Medicare Advantage plan (Part C) that includes prescription drug coverage (most plans do).

Original Medicare does pay for some prescriptions that a medical professional must administer during a hospital stay (Part A) or a doctor’s office visit (Part B).

While Original Medicare (Parts A and B) will cover some drugs in some specific situations, it doesn’t provide extensive coverage for your day-to-day prescription needs.

What Prescription Drugs Does Medicare Cover?

Part A does cover most drugs administered during a hospital stay or skilled nursing facility stay. Part B covers most drugs you don’t administer yourself. Suppose you need chemotherapy, here’s how Part A and Part B work:

• Part A covers the treatment you receive in the hospital
• Part B covers the treatment you receive for an outpatient visit

All coverage is subject to Original Medicare’s coinsurance and standard deductibles.

In terms of your Medicare Part B prescription requirements, here are some other examples of what Part B typically covers:

• Drugs used with durable medical equipment
• Antigens prepared by a doctor and given by an appropriate provider
• Injectable osteoporosis drugs
• Erythropoiesis-stimulating agents
• Blood clotting factors
• Injectable and infused drugs
• Oral end-stage renal disease (ESRD) drugs
• Parenteral and enteral nutrition (intravenous and tube feeding)
• Intravenous Immune Globulin (IVIG) provided in-home

While Part A and Part B help, it’s essential to understand what part of Medicare covers prescriptions you pick up at your local pharmacy or have delivered to you.

For your routine trips to the pharmacy, you will get more financial support from a Part D plan added to Original Medicare or with a Medicare Advantage plan that replaces your Original Medicare plan and includes prescription drug coverage.

Both Part D plans and Medicare Advantage plans are administered by private insurance companies under guidance by the federal Medicare program. A GoHealth licensed insurance agent can help you explore your options.

What Does a Medicare Prescription Drug Plan Cover?

Prescription drug plan (Part D) coverage can vary by plan. Each plan has a drug formulary that shows prescriptions it will pay for and how much it will pay. Each plan has its own set of deductibles and copays, and each plan has a regional network of pharmacies that will fill prescriptions within your particular plan.

The best prescription drug plan is specific to your situation. Whether you’re looking to add a Part D plan to Original Medicare or you want to replace Original Medicare with a Medicare Advantage plan that includes drug coverage, a GoHealth licensed insurance agent can guide you through the process.

What can you expect if you call a GoHealth licensed insurance agent? An agent can compare the costs of multiple prescription drug plans, and not just in terms of the monthly premium. An agent can check your current prescriptions against a given plan’s formulary and help you determine which option provides the bottom line that addresses all of your needs.

Does Medicare cover prescription drugs you currently take? Does Medicare pay for prescriptions you think you might soon take? A GoHealth licensed insurance agent has the answers.

The Centers for Medicare & Medicaid Services (CMS) projected an average Part D  premium for 2024 of $55.50. But the actual out-of-pocket cost can vary quite a bit based on factors like:

• The volume of drugs covered and the extent to which they are covered
• The plan’s deductible and copay levels
• The geographic region that the plan covers (in the case of Medicare Advantage)

Suppose you want to add a Part D plan to Original Medicare. Maybe you want to switch from Original Medicare to a Medicare Advantage plan with prescription drug coverage.

How do you add or switch coverage?

If you want to add Part D to Original Medicare, your first chance is during your Initial Enrollment Period (IEP). If you enroll in Part A or Part B (or both), you can add Part D. You may also gain Part D coverage by switching from Original Medicare to a qualifying Medicare Advantage plan.

If you don’t enroll during your IEP, you can still add a Part D plan during the Medicare Open Enrollment Period, also called the Annual Enrollment Period (Oct. 15 to Dec. 7). During the Medicare Advantage Open Enrollment Period (Jan. 1 to Mar. 31), you can drop, add, and switch Medicare Advantage coverage (including Part D). If you have a Medicare Advantage plan during this period, you can switch to Original Medicare and add Part D.

You also could qualify for a Special Enrollment Period for certain situations like, for example, the loss of drug coverage because you ended a job. After your Initial Enrollment Period, if you don’t qualify for a Special Enrollment Period, you may face late enrollment penalties for not enrolling into a prescription drug plan.

Whether you enroll in Original Medicare or Medicare Advantage, private insurance will provide your Part D coverage. The best way to get Part D with your Medicare plan is to choose your plan during your Initial Enrollment Period (IEP). If you don’t enroll in Part D during your IEP, you can add Part D during the Medicare Open Enrollment Period or the Medicare Advantage Open Enrollment Period.