Does Medicare Advantage cover prescription drugs?
Most Advantage plans include drug coverage, but not all of them. Check the plan's drug list against your own medications before you enroll.
- Most Medicare Advantage plans include prescription drug coverage, but not all do, so check before you enroll.
- If your plan already covers drugs, adding a separate drug plan usually sends you back to Original Medicare.
- Two plans with the same monthly bill can price the same prescription very differently, so compare your own medications.
Most Medicare Advantage plans include prescription drug coverage. Those are called Medicare Advantage Prescription Drug plans, or MAPD plans. A smaller number leave drugs out, and joining one by accident is worth avoiding.
The rule that surprises people: no separate Part D plan on top
Say your Advantage plan already covers drugs. If you then sign up for a standalone Part D plan, you will usually be dropped from the Advantage plan. A standalone plan is one you buy by itself, also called a PDP, short for prescription drug plan.
That puts you back on Original Medicare, which is almost never what anyone intends. Pick one path: a plan with drug coverage built in, or a plan without it plus a PDP. Not both.
There is one exception. A few plan types, such as certain PPOs and private fee for service plans with no drug coverage, do let you add a separate Part D plan. Ask before you assume.
Why the formulary matters more than the premium
Every plan publishes a formulary, its own list of the drugs it will pay for. That list is split into tiers, groups that set what you pay for each drug. A premium is the monthly bill for the coverage.
Two plans can charge the same premium and still price the same prescription very differently. If you take medication every month, this is the largest cost gap between plans, bigger than the premium and often bigger than the copay, the flat amount you pay at the pharmacy.
How to check your drugs against the plan
- Write down every medication you take, with the dose, and whether it is generic or brand name.
- Check each one against the plan's formulary for the coming year, not the list for this year.
- Note the tier each drug falls on, and what you pay at that tier.
- Check whether your pharmacy is a preferred pharmacy for that plan. Preferred and standard pharmacies can charge very different copays.
- Look for restrictions. Prior authorization means the plan must approve the drug before it pays. Step therapy means the plan makes you try a lower cost drug first. Quantity limits cap how much you get at once.
Step therapy is the one to watch. If you are steady on a medication now, being told to switch is a real disruption.
The out of pocket cap
Part D now has a yearly limit on what you pay out of pocket for covered drugs. Out of pocket means money from your own wallet. The limit covers the drug coverage inside an Advantage plan too.
Once you reach it, your covered prescriptions cost you nothing for the rest of the year. That limit replaced the old coverage gap people knew as the donut hole. For anyone on costly medication, it changed the math.
Extra Help
Extra Help is a program that lowers what you pay for prescriptions when your income is under a set limit. Plenty of people in South Texas who qualify never claim it.
Qualifying for a Medicare Savings Program can sign you up for Extra Help on its own. Check even if you assume you earn too much.
Formularies change in January
For the new year, a plan can move a drug to a higher tier, add a restriction, or drop it from the list entirely.
Your Annual Notice of Change, the letter your plan mails you each fall, lists those changes. That letter is the reason to review your coverage even when nothing about your health has changed.
Read how to read the ANOC, then check your medication list against next year's formulary. See how Medicare drug coverage works overall for the wider picture. If you want help comparing your medications, call our McAllen office at (956) 687 3334, or enter your ZIP code in the plan pricing box on this page.
Common follow-up questions
Can I add a separate Part D plan to my Advantage plan?
Usually not. On most Advantage plans that already include drugs, signing up for a separate one drops you back to Original Medicare. Check your plan type first, since a few types allow it.
What if my medication is not on the formulary?
You can ask the plan for an exception, with a letter of support from your doctor. You can also ask about a covered drug that works in its place, or change plans during Annual Enrollment.
Do all Advantage plans include drugs?
Most do, but not all. Confirm before you enroll, because fixing it later means waiting for an enrollment window.
Want this looked at properly?
We are an independent agency in McAllen serving Hidalgo, Cameron and Starr counties. There is no obligation to talk it through.
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Gerino Alejos
Licensed insurance agent · License 3128710 · NPN 18243381
Owner of McAllen Insurance Group, an independent agency on North 10th Street in McAllen. Works with clients across Hidalgo, Cameron and Starr counties on Medicare, Marketplace health, life and auto coverage. Se habla español.