topic Re: BEWARE of Medicare Advantage Plan Drug Coverage Information in Community Chat

BEWARE of Medicare Advantage Plan Drug Coverage Information

Marp — Sun, 09 Nov 2025 16:57:28 GMT

Like many Medicare Advantage plan shoppers my primary concerns are in regard to coverage and cost of my medications and if my PCP is in network.

I usually start my annual search at medicare.gov then follow up by going to the insurance providers website.

Although there were changes (increases in costs) with my current provider I had decided to stay with them.

This is where the BEWARE comes in. A week ago I received a notice from my provider that one of my prescriptions will not be covered in 2026. This is an important medication that not only helps my condition it is very much a quality of life medication.

That notice is in complete opposition to what is listed at both Medicare.gov and the company's own website formulary listing as of today.

The medication in question is very expensive and there is no way I can afford it on my own. I have contacted my insurance provider but have not yet received a reply.

To add insult to injury even through Goodrx and other discounters the cost would be between $380 and $512 a month depending on the pharmacy. The retail price is $552 per month.

The same medication purchased from Canada would be $132 for a three month supply.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Venezia — Sun, 09 Nov 2025 17:10:54 GMT

It's been known for eons that the drug companies and big pharma have ripped off U.S. customers.

The same drugs in other countries cost a fraction of what we pay. The "excuse" is that they have to pay for all the important research somehow. The truth is their stockholders demand higher dividends.

Our government needs to crack down on them. The consumer has no power to change things on his/her own, except at the ballot box and making these demands clear to our elected officials.

Some states allow their citizens to order from Canada. It might be something you could look into.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

kaydee50 — Sun, 09 Nov 2025 17:11:36 GMT

Is there any reason then why you cannot buy it from Canada???

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Linda0215 — Sun, 09 Nov 2025 17:15:05 GMT

@Marp So sorry you are going through this with your insurance. I'm also on several meds that are very expensive to pay out of pocket. I'm still working and covered under my employer's plan but still, at the beginning of the year, it's all out of pocket for me. Literally, thousands of dollars before my deduction kicks in. If I were you, I think I'd research getting my meds from Canada. I did that about ten years ago and saved a substantial amount of money.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

gypsys mom — Sun, 09 Nov 2025 17:17:24 GMT

I don't know if this will help but you can try. My doctor was able to get me my medicine free-they check how much you make with retirement, I think the md tells them why it is so important to your care etc. Ask your doctor about this-will say a prayer it works for you.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Marp — Sun, 09 Nov 2025 17:18:55 GMT

@kaydee50 wrote:
Is there any reason then why you cannot buy it from Canada???

No, @kaydee50, there is not. My warning was primarily due to the misinformation provided to Medicare.gov and on the provider's own website.

If I'm making decisions at least partially based on what prescriptions are covered then the information supplied by the insurance company should be accurate.

I found it particularly egregious that the insurance provider's own formulary information was not updated leading people to believe the medication is covered in 2026 when it isn't. It had been covered for the three years I've taken it.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

RinaQVC — Sun, 09 Nov 2025 17:24:33 GMT

This post has been removed by QVC because

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

UpNorthGorgy — Sun, 09 Nov 2025 17:26:16 GMT

@gypsys mom A friend of mine got her Ozempic free for diabetes. She had to submit income paperwork and receives the Ozempic directly from her Doctor.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

catter70 — Sun, 09 Nov 2025 18:10:15 GMT

I have regular medicare and part D, both the best plans availabe. I called to see if my Anoro Ellipta will be coved next year (it's for COPD) and was told it will not be covered and my cost out of pocket would be over $2000.00 a month. She said I have to have my doctor sent in an authorization and maybe it would be covered. There is no generic for this and I get a reaction from other COPD meds.This is one of the meds that would be cost reduced in 2027 like they've done with diabetes meds.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

willowbark — Sun, 09 Nov 2025 18:38:29 GMT

I also have original medicare with a supplement plan and part D. Part D comes in 3 different tier levels and depending on your pharmaceutical needs it gets progressively more expensive but absolutely better than not having part D. I am in the lowest (cheapest) tier level because my only medication is two different sets of eyedrops for glaucoma. It currently costs me $54.10 per month for Part D and 0.00 at the pharmacy. I'm guessing the $54.10 will go up at some point in the future.

I don't like the new advertisements for something called MAPD. Very deceptive. in my opinion to get you to sign up for an Advantage Plan which I will never do.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

quilter61 — Sun, 09 Nov 2025 18:44:10 GMT

My Medicare Advantage Plan moved one of my drugs to a tier 4. Can't afford it at this tier. This is a generic drug and I can't take any other drugs in this category, due to side effects. I met with my insurance broker this week and she found a plan that covers it at 0 cost. Will probably be changing to this different Advantage plan. It covers all my doctors and some copays are less than my current plan and it has more dental coverage.

There are a lot of changes for 2026 in Medicare plans. I did ask the broker how one plan covers and another doesn't. She explained that probably not many consumers are using that drug in my current plan. It really pays to check this info every year.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Lisa now in AZ — Sun, 09 Nov 2025 18:52:09 GMT

I had the same issue. My regular pain medication that I rely on has been moved from a Tier 2, which cost $12 to a Tier 3, which means I have to pay the whole cost myself until I meet the increased deductible. I have a meeting with my Medicare insurance guy to see what other options I might have. I hate to think that there are people who now have to go without their medication. I would definitely see if you can get it from Canada.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

mrshckynut — Sun, 09 Nov 2025 19:04:00 GMT

@Marp have you tried to find out if you qualify for the medicine discounted from the manufacturer? my spouse did this with 2 of the real expensive ones and qualifed for both of their discount programs

mrshckynut

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Icegoddess — Sun, 09 Nov 2025 19:12:34 GMT

To add insult to injury, Insurers can change their formularies any time they want throughout the year. So, you may sign up for a plan that covers your drugs and then later in the year, they could change the tier of that drug or drop it entirely from their formulary.

On a good note, I listened in on a Webinar given by Boomer Benefits about open enrollment and they said that any drug that required authorization, would likely need to be re-authorized again each year, but that it appeared Insurers would be mostly re-authorizing them.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Rockycoast — Mon, 10 Nov 2025 15:35:14 GMT

My husband and I just compared Medicare Advantage plans. We are staying with what we have. Our advantage plan is great for us. We do not want to change to a different plan.

There is an cost increase of course and we have less dental coverage which is not a big deal to us. We get to keep our doctors and the few meds that we take are still covered. That was the big deal to us. We emailed our agent and let him know we would be staying. He said it sounded good and if any changes or if he thinks a better plan is good for us he would let us know.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Cakers3 — Sun, 09 Nov 2025 19:32:20 GMT

I just received a notice in the mail today that one of my meds will no longer be covered.

When the update went out in September for 2026 coverage it was "Good news! All your prescriptions are covered in 2026 as they were in 2025!"

Yes, they can change in the middle of the year too.
I had a very small copay for this medication but mid 2025 it doubled.

I am very concerned for everyone. Premiums are set to rise and many will lose coverage. This from my PCP, not some off the wall website.

Next year is going to be a disaster.😢

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

kaydee50 — Sun, 09 Nov 2025 19:50:59 GMT

Fortunately, neither DH nor I take any medications. But it bothers me that they can drop a drug or increase the price drastically during the year??? This does not sound legal or ethical to me. It's like changing the rules in the middle of a game. How does this happen??

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

Carmie — Sun, 09 Nov 2025 19:51:39 GMT

Everyone absolutely should review their RX coverage for 2026 regardless if they have an Advantage plan or a Part D RX plan.

There are many changes being made. Some drugs have been dropped and some added. Most notably is the deductible that must be met before anything is covered. For many plans, it is $615. You may not have had a deductible before.

There is gonna be a lot of disappointed people come 2026 because they didn't check their benefits.

@Marp I would advise you to directly call your insurance company and check to see if this drug will be covered or not. Sometimes Providers/doctors get confused with benefits. I would double check just to be 100% sure.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

CelticCrafter — Sun, 09 Nov 2025 20:56:47 GMT

@Carmie wrote:
Everyone absolutely should review their RX coverage for 2026 regardless if they have an Advantage plan or a Part D RX plan.

There are many changes being made. Some drugs have been dropped and some added. Most notably is the deductible that must be met before anything is covered. For many plans, it is $615. You may not have had a deductible before.

There is gonna be a lot of disappointed people come 2026 because they didn't check their benefits.

@Marp I would advise you to directly call your insurance company and check to see if this drug will be covered or not. Sometimes Providers/doctors get confused with benefits. I would double check just to be 100% sure.

@Carmie I disagree with you, you may be the insurance expert, but that's not true. None of my husbands medications are subject to the deductible or a co-pay.

Re: BEWARE of Medicare Advantage Plan Drug Coverage Information

cindyNC — Sun, 09 Nov 2025 22:35:51 GMT

My BF gets a lot of spam/scam calls this time of year from various Medicare Advantage plans. They disguise their name on the caller ID. I got so frustrated one day that I started telling them he was in jail.