Six Things to Know about Your Medicare Advantage plan’s Drug Coverage & Costs


  1. Significant taxpayer subsidies are given to private health insurers through Medicare to provide prescription drug plans (Medicare Part D) to eligible seniors and disabled individuals.
  2. There is no annual limit on your out-of-pocket prescription drug expenses in Medicare Advantage plans.
  3. Private insurers control their drug expenses by restricting their subscribers’ access to medications through the design of their formularies including what medications are excluded, requiring prior insurer authorization, limiting quantities, requiring subscribers to take lower cost drugs before higher cost drugs and establishing different drug price tiers, annual deductibles, co-pays and coinsurance.
  4. There are significant differences among Medicare Advantage plans including the drugs they include and the premiums, deductibles, co-pays and coinsurance that subscribers are required to pay.
  5. Although Medicare Advantage plans are not allowed to deny coverage or charge higher premiums to people with pre-existing conditions and chronic diseases, prescription drug policies that insurers establish provides a clear message of who they want as subscribers.
  6. The cost of medications to treat millions of Americans with life-threating diseases such as diabetes, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, various cancers, organ transplants are all extremely high and most require ongoing medications for life.


Medicare DrugCost

A review of four major Medicare Advantage insurers in Upstate New York including national for-profits: Aetna and United HealthCare and regional non-profits: MVP and Excellus Blue Cross revealed the following observations.

  • All insurers target enrolling healthy seniors and provide incentives of low or no monthly premiums along with gym memberships.
  • All insurers have developed disincentives for subscribers who use “non-preferred” brand name and generic medications by using medication exclusions, deductibles and higher drug co-pays and co-insurance.
  • There are significant differences among insurers in the number of brand name and specialty drugs that they exclude in their formulary.
  • Subscriber co-insurance for Tier 5 specialty drugs can be as high as 33% of the insurers published cost and 100% for drugs that have been excluded from the plan’s formulary. This can result in thousands of dollars of out-of-pocket expenses.

In summary, you may have insurance for your prescription drugs in your Medicare Advantage plan, but you may not have coverage or the ability to pay for your critically needed medications for life-sustaining treatment.

As result,  it is very important that you that you educate yourself and confirm that the Medicare Advantage plans that you considering meet your needs and budget during this Medicare open enrollment period that ends, December 7th.

Buyer Beware in Selecting a Medicare Prescription Drug Plan (PDP)

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Individuals who use original Medicare A & B for their medical care, with or without a Medigap Plan (not a private Medicare Advantage plan), need to check the formulary and costs of various private insurer PDPs that are available in your area very carefully. And, don’t assume that an insurer that provides a good value for one type of plan (eg. MA or Medigap) provides the same quality, value and coverage in their PDPs. Unlike MA plans that include the same medication formulary, PDPs often have different medications, deductibles and co-pays among their various plans, so check carefully.

An example is United HealthCare, who is a leader in sales and value for their Medigap plans in NYS, ranks much lower in sales & value for their MA and PDPs. There are also dramatic differences in the drug formularies and subscriber cost among the 3 different UnitedHealthCare PDPs that are offered.

The UHC Rx Preferred plan includes over 3,500 drugs on their formulary and has their most expensive premium ($91/mo. but does not include a deductible). By comparison, the RX Savers Plus plan excludes over 400 drugs that are included in the Preferred plan for $55/mo. and includes a $405 deductible. And their lowest cost premium plan is the UHC RX Walgreens plan for $26.50/mo. with a $405 deductible, but it doesn’t cover 500 medications that are included in the high premium cost UHC Preferred plan.

Other popular insurers such as SilverScripts, Humana and Cigna that offer multiple PDPs in NYS also share similar issues which makes it difficult for an individual to clearly understand and choose a plan that includes their medications at a price they can afford. provides a valuable, free Plan Finder service that allows you to anonymously enter your medications and your preferred pharmacies and then compare the total cost of different plans (including MAs and PDPs) from different companies that you are considering.

Once you enter your medications You will also see differences in:

  • Your medications that are not included on the plan formulary.
  • Your medications that have restrictions.
  • Your brand named medications that have generic alternatives.
  • Your cost or a one month or a 3 month supply of medications from different pharmacies.
  • And, finally the total comparative cost differences of each plan including their premiums, deductibles and co-pays that you are considering.


Another nice added feature is that your Plan Finder medication data can be printed and is stored anonymously online. It can be retrieved (with your assigned Drug List ID number and Password date for your future review and updating.

Investing some time in objectively comparing coverage and costs differences of your Medicare plan options can save you money and problems in the future.

If you or your family members needs assistance, you can contact the free State Health Insurance Assistance Program at or 800-Medicare.