Prescription Coverage and Medicare: Tips for Patients and Caregivers

Medicare is a federal health insurance program for people who are 65 or older or have certain disabilities. It helps cover costs for hospital stays, medical appointments, and treatments.

Recently, HealthTree hosted a webinar on preferred pharmacies and prior authorization where Financial Advocacy Program Manager, Diahanna Vallentine, shared practical information to help patients and care partners better understand their coverage, avoid common delays, and confidently advocate for the care they need.

In the webinar, Dihanna discussed preferred pharmacies, community pharmacies, and prior authorization. 

Watch the Full Webinar 

What is Medicare Part D?

Medicare does not cover prescription drugs unless you enroll in a Medicare Part D. This is an additional program administered by private insurance companies. Medicare Part D bundles your basic insurance with a separate benefits package that covers outpatient prescription medications. 

What is a preferred pharmacy?

 A preferred pharmacy is an in-network pharmacy. This means it is contracted with your health insurance plan and offers discounted rates for your prescriptions. Preferred pharmacies have negotiated lower drug costs agreements, so when people fill their prescriptions at a preferred pharmacy, they often pay less than they would at other in-network pharmacies. 

What are community pharmacies?

Community pharmacies also play a role in helping people navigate health insurance coverage. These are pharmacies that are found in retail stores, like grocery stores or drugstores. In community pharmacies, pharmacists assist patients in understanding their medication options, finding lower-cost alternatives, and speaking with providers and insurance plans if issues with coverage come up. Working with a pharmacist at a community pharmacy can help you answer important questions about your health coverage. 

What is prior authorization?  

Prior authorization is a process insurance plans use to determine if a medication will be covered. Prior authorization can delay access to medication so understanding how the process works can help patients and care partners prepare documentation and work with their healthcare team to avoid unnecessary delays. 

Ways to save on your medications

 Some of the medications used to treat blood cancer can be extremely expensive, and you may have to be on them for many years.Over time, medications that you have been prescribed may be removed from your plans formulary list.  When this happens, you may be responsible for paying the full cost of the drug. 

There are several ways to save money on outpatient prescription medications. 

The amount you pay for medication coverage depends heavily on the type of Part D plan you choose. Understanding your coverage and other available assistance programs can help you save money. 

Know your plan. Health insurance can be very confusing, and knowing your plan well can help you avoid unnecessary costs and get the most out of your coverage. When you understand what services are covered, which providers are in-network, and how your plan handles prescriptions, deductibles, copays, and coinsurance, you can make informed decisions about your care and use your coverage effectively. 

If you have questions about Medicare in general, call 1-800-MEDICARE to speak with a representative. You can also find information about the basics of Medicare, health and drug plans, and providers and services by visiting medicare.gov.  

Connect with your state pharmaceutical assistance program. State health insurance programs provide free counseling to help people understand their Medicare options. They are able to help with choosing a plan, comparing coverage options, and understanding the details of a plan you selected.  

Explore patient assistance programs. Pharmaceutical companies and nonprofit organizations offer programs that provide financial support or discounts on medication. Knowing about the available assistance programs and finding out if you are eligible can help you manage the costs of your treatment.

Ask about generic or alternative medications. You can also save by asking if a generic version of a medication is available.  Sometimes comparing IV and oral options may be helpful because one may offer better insurance coverage or lower out-of-pocket costs.

Find a HealthTree Coach. HealthTree offers assistance through the Coach program. Here, you can request to be connected with a coach who can answer your questions around financial assistance programs, how they work, and how to apply to them.

The most important thing for you to do is to keep up with your treatment and its associated costs. Know your insurance coverage. Even if you feel you are sufficiently covered, it doesn't hurt to get a second set of eyes on your insurance program or cover details that you may have missed. 

To learn more about navigating Medicare and other topics that affect your care, join one of our upcoming community events. 

Community Events

Sources: 

• Social Security Administration-Medicare 
• AARP-Does Medicare cover prescription drugs? 
• AARP-What to Know About Medicare Part D Drug Coverage 
• Official Medicare Website