Figure out the coverage for your current medications.
To figure out what coverage for your current medicines would be like, take the following steps:
See if your regular prescription medicines are in a Medicare Part D plan's "formulary" list. No single Medicare Part D prescription drug plan covers all prescription medicines. Instead, each plan covers only a selected list of drugs, called the plan's "formulary." The formulary must include at least one drug -- and usually several -- in every pharmaceutical category (meaning at least one drug to treat every disease or condition). If you enroll in a plan whose list doesn't include all the drugs you usually take, that plan probably isn't any good for you. It would force you choose between switching drugs to something that's covered by the plan, or paying the full cost of the noncovered drugs out of your own pocket, defeating the purpose of having a drug plan.
So, your first task when considering any plan is to make sure the plan's formulary includes the drugs you regularly take. You can do this initially on the Medicare website's Prescription Drug Finder. But if you're seriously considering enrolling in a particular plan, make sure to double-check the Medicare site's information directly with the plan itself, before you enroll. Plans often change the drugs they include in their formularies, and they'll have the most up-to-date information on the drugs they cover.
Find out if there are restrictions on any of your regular medicines. Even if a specific drug is included in a plan's formulary list, that doesn't mean you'll have automatic access to it. Plans are permitted to place restrictions on drugs, any one of which could make it difficult for you to get coverage for the medicine you want. Before you enroll in any plan, check with the plan itself to see if any restrictions would apply to any of the drugs you regularly use. These restrictions can include:
Generic only. Some plans list a drug on their formulary but provide coverage only for the generic version, not the brand name.
Substituted drug. Plans are allowed to substitute a different but similar drug from the one prescribed by your doctor, though the substituted drug must be within the same pharmaceutical category. This would be the prescription equivalent of your doctor prescribing aspirin and you being given Tylenol or Advil instead.
Tiered drugs. Insurance companies may place drugs in different tiered categories, charging you higher co-payments for some tiers than for others.
Prior authorization. Plan D insurance plans may require that you and your doctor get prior approval from the plan before it will pay for a particular drug. Even if the plan authorizes coverage, it's an inconvenience for you and your doctor and can delay your getting the drug. If the plan refuses authorization, it forces you either to pay the full cost out of pocket for the drug you and your doctor prefer, or to use a different drug.
Step therapy. For a few medicines, Part D plans require a patient to try one or more other drugs -- other "steps" -- before the plan will cover the drug your doctor prescribed, and it will cover that drug only if the doctor certifies that other steps were not effective.
