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Comparing Plans

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Overview

Medicare promises a choice of at least two plans for every area in the country, although many more are typically offered. In addition to your basic choice between a ‘stand alone' prescription drug plan (PDP) or a Medicare Advantage plan that includes prescription drug coverage (MAPD) described above, there are important differences between plans to consider. Understand that for most people, once you enroll in a plan, you will be locked into it until the next Open Enrollment Period-November 15 through December 31 of each year. People receiving extra help are able to switch more frequently.

What drugs are you taking?

Before you begin comparing plans, list the names of the drugs you are currently taking and the dosages, which you can always double check with your doctor or pharmacist.

You will find a list of all prescription drug plans offering coverage in your area online at Medicare.gov.

If you do not have access to the Internet, or simply want help from someone more familiar with this research, you can get help over the phone. 

What plans are offered in your area?

To choose the best plan for your needs, review all of them in your area. Take your time. Check each plan to determine:

  • the premium, annual deductible and if any coverage is provided through the coverage gap;
  • if all your prescription drugs are covered on the plan's list of drugs, called the ‘formulary';
  • what formulary tier (if any) your drugs are on and the cost implications for you;
  • if ‘prior-authorization' is required by the plan before you can fill prescriptions for any of your drugs;
  • if any of your drugs have quantity limits and how that could affect you; and
  • if the plan's pharmacies are conveniently located.

You may have questions, or simply want to review you choices with someone to make sure you are choosing the best plan for your needs. You can do side by side comparisons of different plans at medicare.gov. If a drug you need is not included on a formulary, or if a plan only covers a generic equivalent of a drug you take, ask your doctor's office for help.

Never guess about substituting your prescription drugs because you find one that sounds like your drug. It is strongly recommended that you call the drug plans directly to verify that your medications are actually covered on the stated formulary tier before committing to enrollment with a plan. 

What are the exceptions?

There is an exception to the general rules for Medicare drug plans for drugs that are given intravenously or by infusion, including Tysabri, Novantrone, and any type of IV steroid. These are billed through Medicare Part B because they require the services of a physician.

Avonex can be covered by Medicare Part B as well, but only if it is administered in a doctor's office. If so, Medicare Part B would pay 80% of the Avonex, and the Medicare beneficiary would be responsible for the remaining 20%. People who inject Avonex themselves would have it covered under their Part D drug plan, as long as Avonex is on their plan's formulary. If Avonex is on the formulary, but on a tier that requires a 25% co-payment, (even higher than the Part B co-payment), exploring the possibility of getting the Avonex injected in the doctor's office may be worthwhile.

Example: Mary is currently in a Part D plan that requires a 25% co-insurance for her Avonex which she now takes at home. To see if she could reduce her co-insurance amount, she asks her doctor if he would be willing to give her the weekly Avonex injections in his office, and he agrees. By doing this, the Avonex will be billed to Part B and Mary's portion will be 20%. Her Part D plan can be used for her other medications, and in comparison to the year before, it will now take her longer to reach the coverage gap. 

Medicare Rights Center

Medicare Rights Center (MRC) is the largest independent source of health care information and assistance in the United States for people with Medicare, and a collaborative partner of the National MS Society.

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Centers for Medicare and Medicaid Services

Medicare is a government entitlement program administered by Centers for Medicare and Medicaid Services (CMS). Visit Medicare’s official website.

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