When choosing a prescription drug plan, there are a few key factors to help determine what kind of Medicare Part D coverage is going to work best for you.
Let’s start with the first step: Do you want a standalone Part D plan or one that’s bundled inside a Medicare Advantage plan (also known as an MAPD)?
This question is critical because it determines how flexible your drug coverage will be in the future.
Standalone vs. Bundled Part D Coverage
If you go with a standalone Part D plan, your medical coverage will come from another source—usually Original Medicare or a Medicare Supplement. If instead you opt for a Medicare Advantage plan that includes drug coverage, the medical and drug benefits are tied together.
When you get a Medicare Advantage Prescription Drug plan (MAPD), the drug coverage is automatically included in the plan. You don’t get to pick and choose which Part D drug plan you want—it comes with the package. If you like the medical side of the plan but not the drug benefits, too bad. You can’t mix and match.
This is why it’s so important to check both the medical benefits and the drug benefits of any MAPD plan before enrolling.
What to Look For in an MAPD Plan
Start by making sure each of your prescriptions is covered. This means checking that:
- The plan has a low deductible or no deductible at all
- You have reasonable co-pays on the drugs you take regularly
- Your drugs are placed in the lower tiers of the formulary
If your drug is in Tier 1 or Tier 2, you’re usually in good shape. If it’s in Tier 3 or higher, that usually means higher costs and possibly restrictions.
What If You Want a Standalone Drug Plan?
If you don’t want to bundle your coverage in a Medicare Advantage plan, you can choose a standalone Part D plan instead. This works best when your medical is covered through:
- Original Medicare
- A Medicare Supplement plan
- A Medical Savings Account (MSA)
- A cost plan
- A PFFS (Private Fee-for-Service) plan
But be careful: you cannot combine a standalone Part D plan with an MA-only HMO, PPO, or HMO-POS plan. It’s against Medicare rules.
This is one of those technical details that can trip people up. If you’re unsure, our team at OnMedicare Insurance Agency in Green Bay WI can help you figure out exactly what combination of plans is allowed and what isn’t.
Understanding the Formulary
Once you know whether you’re choosing an MAPD or a standalone drug plan, the next step is to review the formulary—the list of prescription drugs covered under the plan.
You can do this at Medicare.gov, or even better, use a system like ours that will calculate the total cost of each drug based on the plan’s coverage.
Here’s what you’ll need to enter:
- Every prescription you take
- Exact dosage (e.g., 10mg)
- Form (tablet, capsule, liquid, injection, inhaler, nebulizer)
- Whether it’s generic or brand name
Pro tip: If you’re unsure whether you take the brand or generic version, a rule of thumb is how much you pay. If it’s under $20, you’re likely using the generic. Brand name prescriptions usually cost $50 or more. Of course there are exceptions to every rule, but that’s a good starting point.
Common Restrictions to Watch For
When considering the formulary of covered prescriptions, watch for the following:
- Prior authorization: You need permission from the plan before they’ll cover the drug.
- Step therapy: You must try a cheaper drug first before they’ll approve the one you want.
- Quantity limits: The plan covers a certain quantity of a prescription per month.
- Age restrictions: Some prescriptions are covered differently depending on your specific age range.
Sometimes these restrictions can slow down or block your access to medications you need, so they’re worth checking in advance; however, a good agent will discuss options with you before enrolling. Sometimes these restrictions can help you and your doctor find new or cheaper prescriptions!
Don’t Forget the Pharmacy!
After you’ve checked the formulary, make sure the plan you’re looking at works with your pharmacy. Some plans only contract with certain chains or local stores.
Also check whether your pharmacy is listed as a preferred, standard, or out-of-network pharmacy:
- Preferred pharmacies give you the best price
- Standard pharmacies cost more, but are still covered
- Out-of-network means you’ll likely pay full price
Believe it or not, just switching from a standard pharmacy to a preferred one could save you hundreds of dollars a year.
If you’re flexible with your pharmacy, great—just make sure there’s one nearby that’s covered. If you’re not flexible and only want to use a specific pharmacy, double-check that that pharmacy is covered with your plan. And it’s best if they are a preferred pharmacy rather than standard.
Get Help Comparing All of This
If this feels like a lot to navigate—you’re right. There are dozens of Part D plans out there, and each one has its own quirks, formularies, premiums, and restrictions.
At OnMedicare Insurance Agency Green Bay WI, we help hundreds of people every year run these comparisons. We’ll enter your prescriptions, check the dosages, verify your preferred pharmacy, and compare multiple plans to show you exactly which one is most cost-effective.
Because we do this every day, we can do it quickly—often within a few minutes.
You could do it all on your own, but we’d love to save you the time, stress, and guesswork. Just call us, and we’ll help you figure out:
- Which plans cover your medications
- What restrictions apply to your prescriptions
- How much you’ll pay per month at your pharmacy
- Whether you’d save more with a bundled or standalone plan
There’s no cost to you. Just expert help from a local, licensed agent who knows the market. And if you’re specifically looking for help from an insurance agency in Green Bay WI, we’re proud to serve our community with personalized support.
When it comes to Medicare, the fine print can be overwhelming. That’s why so many people rely on our insurance agency in Green Bay WI to help them avoid the landmines and focus on what really matters: getting the right plan with the right coverage at the right price.
Whether you’re new to Medicare or reviewing your plan for next year, we’d love to help. As a trusted insurance agency in Green Bay WI, our team at OnMedicare LLC takes the time to listen to your needs, understand your situation, and walk you through every option.
We believe your prescriptions should be affordable, your pharmacy convenient, and your plan clear and simple. If that’s what you’re looking for, reach out to an insurance agency in Green Bay WI that actually puts your needs first.
Give us a call or stop in to speak with a licensed agent. OnMedicare is the insurance agency in Green Bay WI that thousands of people trust to help navigate Medicare with confidence.