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Medicare Pharmacy Benefits

Until the advent of Medicare part D, there was no prescription coverage for Medicare recipients. The exceptions to this were drugs prescribed and filled during a hospital stay or patients who had a Medicare Advantage Plan. Medicare Advantage, also known as Medicare part C, is similar to a Health Maintenance Organization (HMO). On January 1, 2006, Medicare part D went into effect and allowed all Medicare recipients to purchase prescription drug coverage.

  1. Coverage

    • Prescription drug coverage for Medicare recipients is not automatic, but has to be purchased. There are many different plans, but all of them offer enough coverage that pharmacy costs are manageable for most people. These plans are purchased through private companies. Specific drugs covered and benefit amounts vary from one company to the next.

    Formulary

    • A formulary is a list of drugs which are covered under a prescription benefit plan. The formulary is different for every company. It is important for anyone considering purchasing Medicare pharmacy benefits to carefully review the formularies before signing. Generally speaking, formularies will cover all generic drugs and most brand name medications when there is no generic version. Co-payments vary but are usually in the range of $5 to $10 per prescription.

    Nursing Home

    • Medicare recipients who have full coverage and reside full time in a nursing home automatically have prescription coverage. There are no out-of-pocket costs for any covered prescription drugs. Medicare recipients with full coverage who live in either an adult living facility, assisted living, or a residential home which is not a nursing home will pay only a small copayment for each covered prescription drug. In all of these cases Medicare contracts with a long-term pharmacy for all medications, thus reducing the cost.

    Durable Goods

    • Medicare provides benefits for clients, including medical products in addition to drugs. Most of these are fully covered if prescribed by a doctor. These products include oxygen and related supplies, also durable items such as a wheelchair, hospital bed, walker, and any other items which may be obtained through a pharmacy or other medical supplier above and beyond medications. All Medicare recipients are eligible for these benefits, whether or not they have part D.

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