Prescription drug coverage is part of an insurance plan

BY SUE WEBBER • CONTRIBUTING WRITER

Prescription drug coverage is a big part of any health insurance plan. And it’s wise to do some research before choosing prescription drug coverage.

“Go to the pharmacist with a complete listing of your medications,” said Steve Langemo, who was a retail pharmacist for 20 years and now has been general manager of Merwin LTC Pharmacy in New Brighton for the last 18 years.

“A pharmacist can check to be sure there are no interactions between the medications,” Langemo said. “Some people double up on medications without realizing it. Also, from a cost standpoint, there might be alternatives that are less expensive.”

Merwin’s LTC Pharmacy in New Brighton is a closed-door pharmacy, which means it is not open to the public. The pharmacy deals exclusively with residents in skilled nursing facilities, according to Langemo.

Long-term care (LTC) pharmacies generally serve the residents of nursing homes, assisted-care facilities, extended-care facilities, and/or retirement homes.

Drug plans may vary in what drugs they cover, and some may have special rules that you must follow before a drug is covered, according to the Medicare website.

Formulary

A formulary is a list of the drugs that a Medicare drug plan covers, according to the Medicare website. It includes how much you pay for each drug. If the plan uses tiers, the formulary lists which drugs are in each tier. Formularies include both generic and brand-name drugs. Each drug plan has its own formulary, so you should check to make sure your drugs are covered.

Coverage rules

Medicare drug plans may require “prior authorization,” the website said. “This means that before the Medicare drug plan will cover certain prescriptions, your doctor must contact the plan for approval,” the website said. “Your doctor may need to provide additional information about why said. “Your doctor may need to provide additional information about why the drug is medically necessary for you before you can fill the prescription. Plans may also require ‘step therapy’ on certain drugs. This means you must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.”

It is a good idea to check with each Medicare drug plan you’re considering to make sure your current pharmacy is in the plan’s network, or there are pharmacies convenient to you. Some Medicare drug plans may offer a mail-order program that will allow you to have drugs sent directly to your home.

Even if you’re not changing plans, make sure your pharmacy is still in your plan’s network next year. Plans may change their network pharmacies each year.

Coverage gap

Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary limit on what the drug plan will cover for drugs. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2016, once you enter the coverage gap, you pay 45 percent of the plan’s cost for covered brand-name drugs and 58 percent of the plan’s cost for covered generic drugs until you reach the end of the coverage gap.

Automatic prescription refills by mail

Some people with Medicare get their prescription drugs by using an automatic refill service that delivers prescription drugs when they are about to run out.

 


 

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