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.