“Is my medication covered?” is the right question asked slightly wrong. The useful version is: is it on this plan’s list, on which tier, with what conditions attached, and at which pharmacy?
Four answers, not one. Here is how to get all four.
Start with an accurate list
Before anything else, write down every prescription you take. For each one you need the exact name, the strength, and how often you take it.
The exact name matters more than people expect. Brand and generic are treated differently. A twice-daily dose and a once-daily dose of the same drug can sit on different tiers. If you have a bottle in the cupboard, copy from the label rather than from memory.
Include everything, including the medication you take rarely and the one you would rather not discuss. A plan that handles four of your five drugs well and the fifth badly is not a good plan for you.
The formulary is the list
Every drug plan publishes a formulary — the list of medications it covers. It is organised into tiers, and the tier decides your share of the cost.
Roughly, tiers run from preferred generics at the bottom to speciality drugs at the top, and what you pay rises as you go up. A medication can be “covered” and sit on a tier that makes it expensive. That is not a trick; it is how the plans are designed. But it means the yes-or-no answer on its own tells you very little.
Formularies are rewritten every year, and plans may make certain changes mid-year. A drug that was tier two in one year can be tier three in the next, and nobody telephones you about it.
The conditions attached
Three restrictions turn up repeatedly, and each has a different practical meaning.
Prior authorisation. The plan will not pay until your doctor explains why you need this drug. Usually resolvable, sometimes slowly, and the delay lands on you at the pharmacy counter.
Step therapy. The plan wants you to try a cheaper drug first. If you have already tried it and it did not work, your doctor can usually document that and skip the step — but somebody has to actually do it.
Quantity limits. The plan will pay for a set amount in a set period. Fine for most people; a problem if your dose is above the standard.
If any of your medications carries one of these, find out before you enrol, not at the counter in January.
The pharmacy matters
Plans have networks of pharmacies, and often a subset of “preferred” pharmacies where your share is lower. The same drug on the same plan can cost you differently depending on where you fill it.
If you use a pharmacy you like — because they know you, because it is walking distance, because they telephone you when a refill is due — check that it is in the network before you choose a plan. Changing plans is easier than changing pharmacists.
Mail order is usually cheaper for maintenance medications and usually a nuisance for anything that changes. It is a reasonable choice for some drugs and not others; you do not have to pick one for everything.
How to check it properly
The official tool is the Medicare Plan Finder at Medicare.gov. You enter your ZIP code and your medications, and it shows what each plan available to you would cost across the year, in your pharmacy. It is free, it is authoritative, and it is available to everybody, including people who never speak to an agent.
Two pieces of advice about using it. First, enter your drugs exactly, including strength. The results are only as good as the list. Second, look at the annual total rather than the monthly premium. The plan with the lowest premium is frequently not the cheapest plan for a person taking three medications, and the whole point of the exercise is to find that out.
You can also telephone 1-800-MEDICARE and have someone walk it with you, or ask your State Health Insurance Assistance Program, whose counsellors do this all day and sell nothing.
If you would rather someone did it with you at a table, that is what we do. We will run the same tool, with your list, and write down what it says. You keep the notes.
When it goes wrong anyway
If a plan refuses a drug you need, that refusal can be appealed, and appeals succeed more often than people expect. Your doctor can request an exception on the grounds that the alternatives are unsuitable for you. Deadlines are short, so start on the day you are refused rather than the week after.
There is a separate guide on appeals. The short version: ask the pharmacist for the written notice, telephone the plan the same day, and get your prescriber involved immediately.
Once a year, whatever happens
In September your plan sends an Annual Notice of Change. It lists what is changing about your coverage for the year ahead, including your formulary.
Open it. Compare it against your list. Then check the Plan Finder again in October, even if nothing has changed for you personally — because something has probably changed about the plan.
This is a thirty-minute job once a year, and it is the single most valuable half-hour in Medicare.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov,1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. Clearview Medicare Advisers LLC is not connected with or endorsed by the United States government or the federal Medicare program.
Not sure how this applies to you?
Tell us your birthday and whether you are still working. That is usually enough for us to say which periods apply to you and by when. No charge and no obligation.
