How to lower your brand-name drug copays with Medicare

Copays for brand-name prescription drugs can be much higher than generic medications. If a generic alternative isn’t available, or you need to take a brand-name drug for any reason, the cost of copays may add up. 

Medicare Benefits Solutions

Sep 3, 2021

 5 minutes read

If you’re enrolled in a Medicare Advantage plan with prescription drug coverage and have been paying too much for your brand name drugs, you may want to consider your options. You may be able to lower your brand-name copays by switching to a different plan.

Medicare Advantage plans with prescription drug coverage, also known as MA-PDs, have different formularies, tiers of pricing, and costs. Compare your current brand-name copays with other MA-PD plans available in your area. If you find a plan with lower brand-name drug copays that will save you money overall, you may be able to switch during an enrollment period.

Finding a plan with lower brand-name drug copays

Review your current coverage. How much did you spend on brand-name copays in the last year? If your out-of-pocket costs have been too high, check out other plans available in your area. Make sure that any current medications you take are included in a plan’s formulary, and compare the cost of copays.

Tiers of pricing can vary among MA-PD plans. Tier 1 usually consists of generic drugs that have the lowest copays. Tier 2 will include preferred brand-name drugs and non-preferred generics. Tier 3 may include non-preferred brand name drugs. Tier 4 (and above) may include specialty or high-cost prescription medications. Costs can vary, but you may be able to find a plan with lower copay costs for the brand-name medications you need by comparing plans.

As you compare MA-PD plans, consider other factors that contribute to your overall costs as well. Even though brand-name drugs may cost less through a particular MA-PD plan, you may find that other costs are higher. Compare out-of-pocket expenses, including monthly premiums, doctor copays, and annual maximum out-of-pocket limits. You may find a plan that lowers your brand-name drug copays, reduces your overall out-of-pocket expenses, and gives you the comprehensive coverage you need.

It can sound a bit complicated to weigh the costs and benefits of different MA-PD plans, but help is available. A knowledgeable, licensed sales agent may be able to help answer your questions and narrow down options based on your personal needs and preferences. And, when you’re ready, they may even help you enroll.

The type of plan you choose may affect your brand-name copays

There are different MA-PDs to choose from. Many Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) include prescription drug benefits, but costs and coverage can vary. HMOs generally have lower overall out-of-pocket costs than PPOs, but PPOs may allow you greater flexibility.

Medicare Advantage Special Needs Plans are required to include prescription drug coverage, but formularies and costs can vary. If you qualify for Medicare and Medicaid and enroll in a Dual-eligible Special Needs Plan (D-SNP), you may get help paying for prescription drugs, and brand-name drug copays may be much lower.

When can you switch to an MA-PD to lower your brand-name drug copays?

You may have the opportunity to make changes to your coverage throughout the year. If you find a plan that will lower your brand-name drug copays and save you money, you may be able to switch during one of the following enrollment periods:

  • Annual Election Period (AEP). From October 15-December 7, you have the chance to switch from one Medicare Advantage plan (with or without prescription drug coverage) to another MA plan. During this time, you can also switch from one Prescription Drug Plan (PDP) to another, or switch from Original Medicare to a Medicare Advantage plan (with or without prescription drug coverage). You could also drop your MA plan, revert back to Original Medicare, and enroll in a stand-alone PDP.
  • Medicare Advantage Open Enrollment Period. From January 1-March 31, you can make one change from one MA plan (with or without prescription drug coverage) to another.
  • Special Enrollment Period. You may be able to switch plans outside of a regular enrollment period if you experience certain life events. For instance, if you move out of your current plan’s service area, move into a skilled nursing facility, or qualify for Medicaid, you may be eligible for a Special Enrollment Period.
 

Ready to potentially lower your brand-name copays?

Brand-name drugs can be costly, but if you don’t have the option of using a generic alternative, you may be able to lower your copays by switching to a different Medicare Advantage plan. If you have questions, or need help narrowing down your options, speak to a knowledgeable, licensed sales agent who can help you find the plan that’s right for you.

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