Prescription drug coverage helps reduce the cost of medications prescribed by healthcare providers. It can be part of a health insurance plan, purchased separately (like Medicare Part D), or added as a supplemental benefit.
Prescription coverage makes medications more affordable for members, especially those managing chronic or acute illnesses. Under the Affordable Care Act (ACA), you can get certain drugs at no cost if they're covered by your plan and you have a prescription. Check your plan details for a list of covered prescriptions.
Key elements of prescription drug coverage
Prescription drug coverage consists of several important components that determine how much you pay and which medications are available to you. Understanding these elements can help you make informed decisions about your health plan and prescription costs.
- Cost sharing: Members are responsible for a portion of the cost of their medications through copayments or coinsurance. This means the expense is divided between you and your insurance plan, helping make prescriptions more affordable while still requiring some out-of-pocket payments.
- Deductibles and coverage stages: Some plans require you to pay a deductible before coverage begins and may include different payment stages. For example, Medicare Part D has certain coverage phases that affect how much you pay throughout the year. Understanding these stages helps you plan for out-of-pocket (OOP) costs and anticipate changes in your payment responsibilities.
- A Health Savings Account (HSA) is one way to help cover OOP costs. An HSA is a medical savings account where you put in pre‑tax money to pay for health care expenses you pay yourself. You (and often your employer) can contribute money to the account, and you can spend it when you need care. It’s like a personal healthcare wallet that gives you a tax break.
- Formulary: Each plan has a formulary, which is a list of covered medicines. It is important for members to check whether their specific prescriptions are included in the formulary to ensure coverage and avoid unexpected costs.
- Tiers of coverage: Prescription drug plans typically organize medications into tiers. Generic drugs are often placed in lower tiers, resulting in lower copays. Brand-name and specialty drugs are usually assigned to higher tiers, which have higher copayments or coinsurance. This tiered structure impacts how much you pay for different types of medications.
Medicare Part D prescription drug coverage
Medicare Part D is for individuals who are on or eligible for Medicare—helping pay for brand-name and generic drugs. It's an optional benefit offered by approved private insurers. Even if you don't take prescriptions now, enrolling early prevents late penalties. See below for more details on the three types of enrollment:
- Initial Enrollment Period (IEP): Your unique 7-month window to sign up for Medicare when you first become eligible. It begins 3 months before your 65th birthday, includes your birth month, and ends 3 months after.
- Annual Enrollment Period (AEP): Also known as Open Enrollment, this runs every year from October 15 to December 7. During this time, anyone with Medicare can change, drop, or add Medicare Advantage or Prescription Drug Plans (Part D), with new coverage starting January 1.
- Special Enrollment Period (SEP): A temporary window triggered by specific, life-changing events (e.g., moving to a new area, losing employer-sponsored health coverage, or qualifying for Extra Help). An SEP allows you to make changes to your plan outside of standard dates.
Some Medicare Advantage plans include Part D as part of their coverage. Learn more about Rx benefits for our Medicare Advantage plans.
For Mass General Brigham Health Plan members
We work with Rx Savings Solutions (RxSS) to help you and your covered family members save money on prescriptions.
This free service is linked to your health plan, so everything is personalized based on your medications. You can access RxSS through the Mass General Brigham Health Plan Member Portal.
Here's how it works:
- Review Rx options: Your online RxSS account shows what lower-cost prescriptions may be available under your plan and lets you compare prices.
- Easily switch: If you choose to make a change, RxSS will consult with your doctor and handle the approval and other details, so you can switch and save with ease.
- Get saving alerts: RxSS will notify you via email, text, or mail when you can save money on prescriptions you’re currently taking, or new ones you’re prescribed in the future.
Members can call 800-268-4476 or visit Member.MGBHP.org/singlesignon/rxss to get started. If you don’t have a Member Portal account, visit the Member Portal sign-on page and select Not Registered Yet. If you have questions, please call RxSS Pharmacy Support at 800-268-4476 (for TTY users: 800-877-8973) Monday through Friday from 8 a.m. to 9 p.m. ET. The RxSS team of certified pharmacy technicians is ready to help explain all your options.
