What You Need to Know About Medicare Drug Coverage If You Have Asthma and Allergies

 

If you’re over 65, you likely have health insurance through Medicare. But coverage for medicines is not automatic – you must sign up for a Medicare Part D plan.

Here is what you need to know if you use Medicare and have asthma and allergies. As with other types of insurance plans, Medicare has an open enrollment period. The enrollment period for Medicare drug coverage began Oct. 15 and ends Dec. 7. Coverage begins January 1, 2017.

If you haven’t yet, take a few minutes and look at your options. Plans are changing so find out which one is best for you next year.

How will my prescription plan change in 2017?

You will likely see your costs rise. And you may see the list of medicines your plan will pay for change. Your plan pays for medicines you need depending if they are on a list called a formulary.

You should review your options to understand:

  • Which drugs your plan covers.
  • Any policies about limiting the drugs the plan pays for. These limits may include:
    • Asking your doctor to say why you need a certain drug before the plan will pay for it (called prior authorization).
    • Asking your doctor to prescribe a different drug in the same class of drugs first (called step therapy).
    • Setting limits on the amount of medicine you can buy at one time.

What if the asthma or allergy drug I need is not covered?

You must pay the full cost for any medicine not on the plan’s list. You can ask your doctor to ask the plan for an exception so that you get the medicine that is right for you.

What is the “donut hole?”

The donut hole is when you must pay a larger portion of the costs for your drugs and continue to pay your monthly premium to keep your coverage. It is also called the coverage gap.

In 2017, people in the donut hole will pay 40% of the cost of brand-name drugs on their plan’s formulary. And they will pay 51% of the cost of generics medicine. With these changes, your current plan may or may not be the best plan for you in 2017.

How do I know if I have chosen the best plan?

Use this tool from Medicare to compare plans. Compare your current plan with the 2017 options. You may find a plan with better or cheaper coverage for the medicines you take for asthma and allergies.

In addition, check to see if the plan covers the drugs you need when you are in the donut hole. Go to the Drug Costs & Coverage tab on the Your Plan Comparison page on the Plan Finder. It will show your estimated monthly costs for each plan you are considering, how those costs will or will not change during the donut hole, and by how much.

Depending on your needs, plans with additional drug coverage in the coverage gap may not save you money if other costs are higher. Look at the total amount, including monthly premiums and cost sharing.

What if I don’t want to make a change?

You can likely keep the plan you have now. But it may not be the best one for your situation.

Where can I get more help to make this decision?

Every state has a State Health Insurance Assistance Program (SHIP) that offers free help to people with Medicare and their families. To find contact information for the SHIP office closest to you, visit www.shiptalk.org or call 1-800-MEDICARE (TTY: 1-877-486-2048).

For additional information, see these questions and answers from MapRx - Medicare Access For Patients Rx™ about Navigating the Prescription Drug Program.Download PDF

The Asthma and Allergy Foundation of America (AAFA) is a member organization of MapRx. AAFA's Action Network has more details about health care, including Medicare.

 

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