Medicare Drug Coverage Doesn’t Ensure Easy Access to Meds

Consumers with traditional Medicare and Medicare Advantage plans face various hurdles in getting their medications, according to an analysis by HealthPocket. Some plans cover more than twice the number of drugs as do other plans. For 16% of drugs, plans limit the quantity that members are allowed to purchase at one time; 18% of drugs requir prior authorization; and nearly 2% requir step therapy in which a member must first try a less expensive medication. Steve Zaleznick of HealthPocket said, “Annual enrollment is coming up in October…The first step…is to ensure that the drugs they take are on the plan’s formulary, and the second is to look at what restrictions they can face in actually getting the medication in hand.”

Each Medicare plan has a formulary, which lists the drugs that are covered and the consumer’s out-of- pocket costs for those medications in a given year. A consumer would have to pay the full cost of a drug that’s not on the formulary. Plans can restrict access to drugs that are on the formulary by limiting the quantity, requiring prior authorization, and mandating step therapy.

Kaiser plans have no quantity limits or step therapy rules and only 3.5% of its drugs are subject to prior authorization. This model can prove useful to industry and government for new and reformed Medicare and private plans that come online through the Affordable Care Act, according to the analysis. For more information, visit

Last Updated 08/10/2022

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