Which Pharmacies Can You Use with Medicare Part D? - dummies

Which Pharmacies Can You Use with Medicare Part D?

By Patricia Barry

Copyright © 2015 AARP. All rights reserved.

This discussion explains the choices that Medicare Part D plans offer for filling prescriptions: getting your drugs at a retail pharmacy, by mail order (if your plan offers that option), at a specialty pharmacy that stocks and handles certain types of drugs, or at a long-term care pharmacy that caters to people living in nursing homes and other institutional facilities.

Of course, you don’t have to choose just one pharmacy or pharmacy type and stick with it. If you want to use mail order for some prescriptions (such as 90-day supplies of drugs you take regularly) and a retail pharmacy for prescriptions of 30 days or less, that’s your call.

You can find out which in-network pharmacies your plan uses — and any that it designates as preferred pharmacies, where you may pay a lower co-pay for your prescriptions — on Medicare’s plan finder or in the plan’s information materials.

Retail pharmacies

A retail pharmacy is a bricks-and-mortar pharmacy that you walk into (as opposed to the mail-order pharmacies that you visit only on the end of a phone or online). Part D plans use a variety of retail pharmacies: large chains, dispensing facilities in supermarkets, and small independent pharmacies.

Every Part D plan has its own network of retail pharmacies — those that accept the plan’s card. And every plan must ensure that at least one in-network pharmacy is within a reasonable distance of enrollees’ homes. What’s a reasonable distance? That depends on where you live:

  • In an urban area, you’re likely to have dozens of in-network retail pharmacies to choose from — many within half a mile or so, and some within walking distance.

  • In a very rural area, getting to the nearest in-network retail pharmacy may mean driving 20 miles or more. If only one pharmacy is within that sort of distance, all the Part D plans in the area are likely to include it in their networks.

Mail-order pharmacies

Most plans offer a mail-order service for filling prescriptions, though not all do. Using this option can be convenient and may save money. But when deciding about mail order, consider the following:

  • You can purchase 90-day supplies only, so mail order is best used for medicines you take regularly over a long period of time.

  • Your drugs are mailed directly to your home, which may be convenient, especially if you’re homebound or live miles from the nearest retail pharmacy in your plan’s network. Shipping is free.

  • Many plans (though not all) offer discounts for mail order. If so, your costs may be lower than at a retail pharmacy.

  • Because you pay for a three-month supply in advance, you pay more upfront than if you buy a 30-day supply each month. In certain circumstances, you may fall into the doughnut hole earlier as a result.

  • You have to remember to phone in your next prescription or reorder online and allow time for delivery (usually seven to ten days) to ensure you don’t run out of your meds before the new ones arrive.

To find out how to use your plan’s mail-order service, check out the plan’s info packet, go to its website, or call its customer service number. Regardless, you’ll probably need to fill out a form to request this service.

Specialty pharmacies

Certain drugs — such as some drugs used for cancer, transplant rejection, multiple sclerosis, and other treatments — must be handled extra carefully when they’re being dispensed. If you take one of these types of drugs, you need to purchase it at a specialty pharmacy that’s equipped to handle it. (The Food and Drug Administration allows some of these drugs to be distributed only to specialty pharmacies.)

The specialty label may be applied to a regular pharmacy that meets the conditions for dispensing these drugs, to a hospital pharmacy department, or to a doctor’s office. Your plan’s pharmacy list should indicate which specialty pharmacies are in-network.

If no in-network specialty pharmacy is in your area, you can go out of network, but call your plan first for guidance. Some Part D plans don’t offer mail-order service for these kinds of drugs.

Long-term care pharmacies

Nursing homes use special long-term-care (LTC) pharmacies that dispense prescriptions in special packaging — the drugs come in single, individually sealed doses rather than the usual containers. This system is for hygiene and safety reasons in a setting where nurses administer many different drugs to many patients. LTC pharmacies may be large companies that supply only nursing homes and other LTC facilities or be local retail pharmacies that can supply properly sealed medicines.

All Part D plans must include LTC pharmacies in their networks. If the ones your nursing home uses aren’t in your plan’s network, Medicare expects the plan to contract with those pharmacies so that you don’t need to change to another plan.

However, when you enter a nursing home, you (or your caregiver) should check whether its LTC pharmacy is in your Part D plan’s network. If it isn’t, call the plan to see whether it will cover drugs supplied by the home’s LTC pharmacy. Or consider switching to another plan that does have this pharmacy in its network. Keep in mind that you have two important rights when you go into a nursing home:

  • You can switch to a different Part D plan immediately (without waiting for an open enrollment period).

  • Your current Part D plan must cover all the drugs you’re taking when you first enter the nursing home for at least 90 days, even if the LTC pharmacy the home uses doesn’t cover some of them. This three-month period allows you time to switch to another plan if you need to.