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Choosing the right Medicare plan

It’s important to consider current and future health needs when it comes to choosing a Medicare plan. Simply asking the right questions can help make sure a plan is a right fit for the enrollee.

There are two main ways to get Medicare coverage.

Option 1:
Original Medicare
Part A (Hospital insurance)
Part B (Medical insurance)		 Option 2:
Medicare Advantage (MA)
Part C
Includes Parts A and B and most often part D
Doctor options No restriction on doctors or hospitals that takes Medicare, anywhere in the U.S. Members in many cases can only use doctors and other providers who are in the plan’s network and service area for non-emergency care. Some plans offer non-emergency care out of the network, but typically at a higher cost. You may also need to get a referral to use a specialist.
Benefits Covers most medically necessary services and supplies in hospitals, doctors’ offices, and other health care facilities. Does not cover some benefits like eye exams, most dental care, and routine exams. Covers all medically necessary services that Original Medicare covers. And generally includes added benefits and prescription drug coverage that Original Medicare doesn’t cover. Added benefits vary by plan selected and service area.
Coverage abroad Coverage generally does not extend outside the U.S. or its territories.

Enrollee may be able to buy a Medicare Supplement Insurance (Medigap) policy that covers emergency care outside the U.S. 		Plans generally do not cover medical care outside the U.S. Some plans may offer a supplemental benefit that covers emergency and urgently needed services.

Enrollees may wish to purchase a travel insurance policy that includes health coverage before traveling outside the U.S.

Picking a plan that provides prescription drug coverage

Generally, Original Medicare doesn’t cover prescription medication. This means an enrollee must add a separate prescription drug plan (Part D).

The other choice is to go with a Medicare Advantage (MA) plan that includes prescription drug coverage. Often these “bundled” MA plans include Part D along with Part A and Part B coverage. Individuals should check and confirm Part D is included when joining an MA plan if they want it included.

Important to note: Adding prescription drug coverage at a later date may result in penalties.

When choosing any of these plans, consider:

  • What drugs does a plan cover?
    Each Medicare drug plan has its own list of covered drugs or formulary. The formulary places drugs into different prescription pricing tiers.
    What happens if a plan doesn’t cover a member’s medication?
    The member’s doctor can request an exception to add it to the plan’s formulary. If the plan grants the exception, the member generally pays the highest pricing tier.
  • Can any pharmacy be used?
    All Part D plans have a network of pharmacies to use when filling prescriptions. Some plans also include a list of preferred pharmacies. Enrollees save more money when using a preferred pharmacy. Members should switch to a preferred pharmacy when it makes sense to do so.

If a member uses a pharmacy not in the plan’s network, they may have to pay the full amount for prescriptions.

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