5 things to know about your prescription drug coverage

Medications can be a big part of your health care expenses, so it’s good to know how your pharmacy benefits work. 

Sari Harrar
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Take a peek inside your medicine cabinet. Chances are there’s more than a pain reliever or fever reducer in there. Most older adults — 9 out of 10 — take at least one prescription medication, according to the Centers for Disease Control and Prevention. But many don’t fully understand how their insurance coverage works for prescriptions — a gap that could get in the way of using medications safely, effectively and affordably.

Consider this: Thirty percent of older adults said that Medicare was somewhat or very difficult to understand, according to a 2018 Centers for Medicare & Medicaid Services survey. Other recent surveys show that many Americans struggle to define basic health insurance terms — deductible, copay, coinsurance and out-of-pocket maximum — that play major roles in determining their personal health care costs.

Understanding and making the most of your prescription drug coverage can help you stay on track with your medications. That’s important for managing health conditions and staying healthy. 

Get started with these five important things to know about your UnitedHealthcare® Medicare Advantage prescription drug plan.

1. It’s Easy to Check Prescription Coverage 

It’s important to know whether your health plan covers the medications you take — and whether you and your doctor will have to take extra steps so that they are covered, or choose alternatives. 

Your plan has a list of covered medications, also called a Formulary or a Drug List. The Drug List includes the generic and brand names of all covered medications. If your drug is not on the list, there is generally another option that treats the same health condition. It’s wise to check the updated Drug List every year for changes that will affect you, even if you have kept the same Medicare Advantage plan.

Checking to see if your drug is covered is easy when you visit the Pharmacies & Prescriptions page of your plan website, MyUHCMedicare.com. You can also access a copy of the Drug List online. Or call the Customer Service number on the back of your member ID card to request a paper copy or ask about your medications by phone.

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2. There May Be Extra Steps for Coverage 

Some medicines have limits or require extra steps before they can be filled. On the Drug List, you might see codes listed that detail any restrictions that apply to your medications. Common codes include:

  • PA: Prior authorization. You or your health care provider need prior approval for a drug, to make sure it is being used correctly for your health condition.
  • ST: Step therapy. You may be required to use another effective, lower-cost medication for your condition first.   
  • QL: Quantity limit. The plan may limit the amount of a drug you can fill at one time to ensure that it is used safely and effectively.

If your drug has one of these requirements or limits, you can call Customer Service for assistance to help you get your needed medication. 

3. Why the Price May Change

The amount you’ll pay out of pocket for a medication depends on many factors, such as the drug’s cost-sharing tier, the drug coverage stage you are in, and if you receive extra help from Medicare. Learn more about the cost of your medications by taking these steps:

Step 1: Know the drug tier. On your plan, medications are assigned to a tier. The tier tells you what your copay (a set price) or coinsurance (a percentage of the total price) will be. Generally, the lower the drug tier, the lower the amount you pay. Tier information is found on your plan’s Drug List.

Step 2: Know your coverage stage. Medicare Part D prescription drug plans have a yearly cycle of coverage stages that affect a drug’s price:

  • Yearly Deductible Stage: If your plan has a deductible (some plans or tiers do not), this is your first stage of the year. You pay the full retail price for your drugs until you reach the deductible amount. The deductible may not apply to all drug tiers. 
  • Initial Coverage Stage: In this stage, you pay a copay or coinsurance for your drug, and UnitedHealthcare covers the rest. If your plan has a prescription drug deductible, you enter the Initial Coverage Stage after you’ve met the deductible. If your plan does not have a deductible, you begin the year in this stage. The Initial Coverage Stage continues until your total drug costs (your payments plus the amount paid by your plan) reach $4,130 in 2021.  
  • Coverage Gap (“Donut Hole”) Stage: You pay 25% of the cost of generic and brand-name drugs, until your total out-of-pocket costs for the year reach $6,550 in 2021.
  • Catastrophic Coverage Stage: You pay a low copay or coinsurance for the rest of the year.

If you get extra help from Medicare to pay for your prescription drugs, your costs and coverage stages will be different. Refer to your LIS Rider for more information.

Have concerns about paying for your medicines? Ask your health care provider about switching to lower-tier drugs.

Learn What You’ll Pay for Prescriptions

Find out what coverage stage you are in and what you can expect to pay at the pharmacy by visiting the Pharmacies & Prescriptions page on your plan website.

4. You Have Options for Filling Prescriptions 

Your plan covers prescriptions filled at a network retail pharmacy. Or you can set up home delivery. 

If you go the neighborhood pharmacy route, there are thousands of national and independent pharmacies in your plan’s network. Find a network pharmacy on your plan’s website or call the Customer Service number on the back of your member ID card to find the one that’s most convenient for you. Except in some emergencies, medications may not be covered at pharmacies that are not in your network.

If you take more than one medication on a regular basis, your health care provider or pharmacist can help you simplify refills. Options include changing your refill dates so that several drugs can be refilled at the same time or switching to a 3-month supply from your pharmacy. You’ll make fewer trips to the pharmacy and have less to keep track of on your own.

If you like the idea of having your medicines delivered right to your home, OptumRx® is the preferred home delivery pharmacy for most plans. You may even save money on your copays when you fill your prescriptions with OptumRx1.

Setting Up Home Delivery is Simple

Want to get set up with home delivery? You can order your prescriptions by signing into your plan website and going to the Pharmacies & Prescriptions tab. 

5. You Can Give a Trusted Person Access to Your Plan 

Sharing access with someone you trust is a smart strategy for understanding your prescription drug plan. To authorize your spouse or another trusted person to speak with UnitedHealthcare about your account, fill out the Authorized Representative form on the “Plan Documents and Resources” page of your plan website or call Customer Service. 

Benefits, features and/or devices vary by plan/area. Limitations and exclusions apply.


1.OptumRx is an affiliate of UnitedHealthcare Insurance Company. You are not required to use OptumRx home delivery for a 90–100 day supply of your maintenance medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to Optum Rx before it can be filled. Prescriptions from OptumRx should arrive within 5 business days after we receive the complete order. Contact OptumRx anytime at 1-877-889-6358, TTY 711.