Managing Your Health Care
Private Health Care Coverage Understanding Your Policy Tips on Fighting Back Appeals, Grievances, and Complaints Prescription Drugs Medigap and Long-Term Care Insurance Medical Billing Protecting Private Information Questions about COBRA and Continuation Coverage Government Programs and Assistance Glossary of Terms
The costs of prescription drugs have skyrocketed over the years and many people lack health coverage for them. In addition, drug pricing schemes are complex. Prescription drug costs are affected by a lot of factors and can vary greatly from one source to another. Pharmaceutical manufacturers negotiate prices with drug purchasers. Discounts are generally greater for large-volume purchasers such as hospitals, employers, or managed care companies. By contrast, smaller-volume purchasers, such as individuals, may not have access to such discounts. Here are some things you can do to help reduce your out-of-pocket costs for prescription drugs:
- Ask your doctor or pharmacist if there is a generic equivalent to a brand-name drug that would be appropriate to treat your health condition. Generic drugs are often less expensive than their brand-name equivalents.
- Comparison shop. As with any purchase, shop around for the best price. Ask your doctor or pharmacist how you can get the most for your money.
- If you have health insurance with prescription drug benefits, make sure you understand what your plan covers. In particular, figure out if the health plan’s formulary includes the drug prescribed for you.
- If you want a drug that is not on your formulary, there are options that may apply. First, if your plan is an HMO, Minnesota regulations require the HMO to offer all medically necessary prescription drugs. So, if the drug you need is not on the formulary but it is medically necessary, the HMO must cover it. In addition, if the drug in question is not on the HMO’s formulary but the formulary drug causes an adverse reaction, is contraindicated, or the doctor demonstrates that the non-formulary drug must be dispensed as written, the HMO must cover the non-formulary drug. Second, if a health plan provides for prescription drug coverage it also must cover prescribed antipsychotic drugs.
- If you are a veteran, contact your local Veterans Affairs Office to find out if you qualify for discounts on prescription drugs.
- Ask your doctor or pharmacist how long you will need to take the medication and in what dosage. This way you can just buy what you need. If you must take a drug for a long time, check to see if you can buy the drug in bulk.
- Understand and follow the directions for taking your medications. This will make the drugs most effective and help reduce the risk of side effects. Avoid potential problems by telling your doctor or pharmacist what other drugs you take, including herbal remedies and over-the-counter medicines. Don’t discontinue or change the dosage of your medication without your physician’s approval.
- Contact the Senior LinkAge Line at (800) 333-2433 for assistance in determining whether you may qualify for free or discounted prescription drugs through a drug manufacturer patient assistance program. People of all ages may apply for patient assistance programs, but each program is different and most have income and/ or asset guidelines. You may also visit the Minnesota Board on Aging at www.mnaging.org for further information about drug manufacturer patient assistance programs.
Medicare Part D Prescription Drug Benefit
A prescription drug benefit under Medicare, known as Part D, is available for people enrolled in Medicare. The drug benefit is offered through two types of private health plans:
- Stand-alone Prescription Drug Plans (PDPs) that supplement the original Medicare plan; or
- Medicare Advantage (Medicare’s version of managed care) plans that provide drug coverage and other Medicare-covered benefits.
Importantly, while Medicare requires all plans to offer certain types of drugs, Medicare does not require that all plans offer the same drug formulary. This means that before you sign up for a plan, you should make sure that the plan’s formulary covers your drugs in the dosage that you need. Formularies can change from year to year, so check your plan’s formulary during the Medicare open enrollment period to make sure your plan still carries the drugs you need.
Part D plan benefits and cost structures vary widely. All Part D plans must offer either the standard benefit or a benefit of equal value, and plans may also provide enhanced benefit options for a higher monthly premium. The standard benefit requires enrollees to pay: a monthly premium set by the plan; a deductible; 25 percent cost-sharing up to the initial coverage limit; 100 percent of drug costs until their out-of-pocket spending reaches a set limit (this is known as the “donut hole” gap in coverage); and a small co-pay or 5 percent of their drug costs thereafter, whichever is higher. Certain low-income beneficiaries are eligible to receive assistance with their Part D costs.
Additional information and assistance with Medicare Part D is available online, at www.medicare.gov, or by calling (800) MEDICARE. You may also contact the Senior LinkAge Line at (800) 333-2433 for assistance with Medicare Part D.