My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?

Question

Diana Garner · Accepted Answer

Before making any decision, you should review both options. Check the cost of your medications with a standalone Part D plan and the Medicare Advantage plans with drug coverage.

When on Medicare, you have the option to select a Medicare Supplement with a Standalone Part D plan (prescription drug plan) or select a Medicare Advantage plan with prescription drug coverage.  

The option you choose will depend on your budget and income. I would never recommend someone have just Medicare A & B with a Standalone Part D plan because then they would be responsible for all of the Part A & B deductibles and copays.

Once you decide which option is best for you based on your budget, you can search for the Standalone Part D or Medicare Advantage plan with drug coverage that is best for you based on your medications.  

As a broker, it is my responsibility to help my clients find the perfect fit.

Norman Smith · Answer

Firstly, my recommendation is to stay away from the MA plans, as your healthcare will be limited as to choices on your health. Especially when there is NO UNDERWRITING involved in your Open Enrollment, get the best while you can and keep control of your health always. MA means giving the control and the choices to a private company who doesn’t even know you!!!
The Prescriptions and pricing are based on a Tier level through the Medicare Part D. Depending on the plan chosen, your drugs will have different pricing. For 2025, between Premium and covered drug costs, you will not have more than $2,000 out of pocket expense. This is a great improvement over previous years!
If they can be administered at your PCP’s or other Medical Professionals office, they would be covered under your Part B. So, do what you can there!

Gary Church · Answer

The reality is that some medications are very expensive. Whether you are on original Medicare with a stand-alone Drug plan or have a Medicare Advantage plan, the issue is that Congress must allow Medicare to negotiate all drug pricing for Medicare patients. Big Pharma needs to be accountable for controlling the cost of its drugs.

Answered by Gary Church on June 18, 2025

Broker Licensed in Ca, AZ, NV & TX

Answered by Gary Church Medicare Insurance Agent

William Lawler · Answer

I am diabetic and I am on a Medicare Advantage plan. Insulin costs are capped at $35/mo. Other meds, like Ozempic, are not inexpensive, but they are available.

Tasha Riggs · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/my-diabetes-medication-is-super-expensive-and-ive-heard-horror-stories-about-part-d-not-covering-what-people-need-should-i-go-standalone-part-d-or-get-it-through-a-medicare-advantage-plan#tasha-riggs

Misty Bolt · Answer

IT DEPENDS ON THE MEDICATION YOU ARE TAKING. OUR JOB IS TO A MAKE SURE YOUR MEDICINE AND DOCTORS ARE COVERED

Charles Fletcher · Answer

A knowledgeable broker, such as myself, will gather your prescription list and preferred pharmacy and help you compare standalone and Medicare Advantage drug plans. In my experience, these days, the MA plans are usually a little less expensive when compared with PDP plans all things being equal.

Answered by Charles Fletcher on April 4, 2025

Agent Licensed in WA, AZ, ID, NV & TN

Answered by Charles Fletcher Medicare Insurance Agent

Jonathan Potter · Answer

Choosing between a supplement and Medicare Advantage is a individual choice. One option is not perfect for everyone. I would get with your agent and have them evaluate both options with the following information: List of Doctors, dentists and any medications that you take. They can take that information and calculate the best option for you.

Answered by Jonathan Potter on June 9, 2025

Broker Licensed in UT, AZ, CA & 14 other states

Answered by Jonathan Potter Medicare Insurance Agent

David Quintal · Answer

Whether an individual chooses a Part D plan or a MAPD, in each case a thorough review of the relative costs associated with each option should be done prior to enrolling into a plan. Sitting with a local and knowledgeable broker is one way to ensure that when a decision has to be made the Medicare beneficiary is aware of the plans premiums, deductibles, copays and formularies. All of these can impact prescription costs.

Answered by David Quintal on April 29, 2025

Broker Licensed in NH, AL, AZ & 14 other states

Answered by David Quintal Medicare Insurance Agent

Steven Bleicher · Answer

Both of these options can be equally problematic, I am sorry to say! The main dilemmas are the Brand Name drugs especially those advertised on TV. You will need to do some extra homework since you face a choice of using your Part D program OR using an online US or Canadian discount website like to GoodRx.com, pharmacychecker.com, simplecare.com, costplusdrugs.com and many others. Just be sure that you use the drop-down menus on these sites to ensure the correct dosage, frequency of use and how many times a day you must take them. This will show you the least expensive copay for the Rx. Don't forget that the maximum $$ that you will spend this year on ALL your Rx's is $2,000.00, tops! Every new calendar year that will begin all over again.

Answered by Steven Bleicher on May 28, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Barbara Barnes, CMIP® · Answer

In my opinion, you are asking the wrong question. The question should not be whether Medicare Advantage or a standalone prescription drug plan is best for you to pay for your medication, the question is what plan will best cover my medication? you need to carefully look at the formulary of each plan that you’re considering to see which plan will cover most or all of your medications and at what cost. The formulary is very important because if your medication is not covered on a plan formulary the cost of that medication does not count toward the $2000 maximum out-of-pocket if you have a chronic special needs plan for diabetics in your area, I would start by looking at that plan first. A chronic special needs plan for diabetes is more likely to cover exactly what you need to treat diabetes than any other plan. In my area of the country, however, we do not have a chronic special-needs plan for diabetes. So in this area, I would be looking closely at the formularies for all available plans to see which plan would do the best at covering the medication’s that you use, keeping in mind that those medication needs may change in the future. you need to have a discussion with your doctor about any other medication‘s that they are thinking about possibly prescribing for you in the future, so that you can check to see that any plan you would purchase would also cover those medications. Once you’ve looked at which plan is best for your medication’s, you then need to look at which plan is going to be best for your medical needs. it doesn’t help you to save money on prescriptions only to spend it in lab tests and hospitalizations. It may be worthwhile to pay for some of your medications on your own so that you have better coverage if you need to go into the hospital or have major surgery or use a skilled nursing facility. these are all things that you need to consider.

Answered by Barbara Barnes, CMIP® on June 22, 2025

Agent Licensed in PA

Answered by Barbara Barnes, CMIP® Medicare Insurance Agent

Michael Yost · Answer

There's been some nice changes in the drug structures of Medicare, especially with diabetes medications. That's where meeting with a broker (someone like us) can help compare the drug plans in your county with the medications you take, to see what the better route to go is.

Answered by Michael Yost on April 10, 2025

Broker Licensed in OH, AL, AZ & 27 other states

Answered by Michael Yost Medicare Insurance Agent

Satoshi Aoki · Answer

I cannot say it is covered, and how much depends on what kind of medication you take and the Part D plan provided by the health insurance company. You should contact Medicare agents and make an appointment.

Answered by Satoshi Aoki on March 31, 2025

Agent Licensed in CA

Answered by Satoshi Aoki Medicare Insurance Agent

Deb Haley · Answer

The drug formulary for each of the carriers is typically the same whether the medications are bundled in on their Medicare Advantage plan offering or on a standalone part D plan that they offer. The difference in price is that with the Medicare Advantage plan the prescription coverage is bundled in and there is no additional premium. The standalone Part D plans have a monthly premium that you pay in addition to your annual drug deductible s and copays. It would make sense to look at both options to see if there is a significant difference in price either way. The choice to go on a separate Part D plan may also be influenced by whether or not all of your medical providers are in network for a particular Medicare Advantage plan.

Answered by Deb Haley on April 11, 2025

Broker Licensed in MA, CT, FL & 10 other states

Answered by Deb Haley Medicare Insurance Agent

Heather Borlenghi · Answer

What do you have now for insurance coverage? A stand alone drug plan and a Medicare Advantage plan with prescription drug coverage do the same thing. One is not better than the other. I would guide you based on more information needed.

Answered by Heather Borlenghi on April 21, 2025

Agent Licensed in GA, AL, AR & 15 other states

Answered by Heather Borlenghi Medicare Insurance Agent

Fred Manas · Answer

Standalone Part D Plans:
Flexibility: You can generally choose any pharmacy that participates in the plan, & you're not limited to a specific provider network. 
Coverage: Part D plans cover a wide range of diabetes medications, including insulin & other oral medications. 
Formulary: While Part D plans have formularies (lists of covered drugs), they may be more flexible than some Medicare Advantage plans. 
Prior Authorization: Some Part D plans may require prior authorization for certain medications, but this is less common than in Medicare Advantage plans. 
Cost: Part D plans can vary in price, so it's important to compare premiums & copays. 
Special Considerations: The Inflation Reduction Act significantly reduced the cost of insulin, limiting out-of-pocket costs to $35 per month. If you have limited income & resources, you may be eligible for Extra Help to lower your drug costs. You can also explore patient assistance programs offered by pharmaceutical companies. 
Medicare Advantage Plans (MA-PDs):
Comprehensive Coverage: MA-PDs typically offer all the benefits of Original Medicare (Parts A and B) plus drug coverage (Part D). 
Provider Networks: MA-PDs often have specific provider networks, which may limit your choice of doctors & pharmacies. 
Prior Authorization: Some MA-PDs may require prior authorization for certain medications, even if they are on the formulary. 
Cost: MA-PDs can have lower premiums than standalone Part D plans, but copays &  deductibles may vary. 
Coordination of Care: MA-PDs may offer additional services like preventive care & chronic disease management, which can be helpful for people with diabetes. 
Special Considerations: MA-PDs may have more strict rules about which medications are covered, & it's important to check the formulary.  You may also need to obtain a prescription for any medications from your primary care physician. Some diabetes-related supplies like syringes, gauze & alcohol may also be covered by MA-PDs.

Vachik Chakhbazian · Answer

For your expensive diabetes medication, both standalone Part D and Medicare Advantage plans can offer drug coverage, but the best choice depends on your specific needs and situation.

Deborah Webster · Answer

Either way insulin are now capped at 35 per month you do need to make sure the insulin you are taking is on the formulary of the plan. That is where an agent like myself can help guide you through the plans.

Answered by Deborah Webster on April 15, 2025

Broker Licensed in Ia & SC

Answered by Deborah Webster Medicare Insurance Agent

Sonya Chandler · Answer

The affordable care act has lowered the cost for covered insulin to more than $35.00.  This cost is the same whether you're on a Part D Plan or a Medicare Advantage Plan.

Bud Griffin · Answer

Every Part D plan available in your zip-code will cover different diabetes medications and have different co-pays or coinsurance charges that you will be responsible for. You should compare the plans available in your zip-code to be able to make an informed decision. I offer plan comparisons free of charge and wilhout any obligation to enroll.

Answered by Bud Griffin on June 23, 2025

Broker Licensed in TX

Answered by Bud Griffin Medicare Insurance Agent

Mitchell Nunn · Answer

I always tell clients the same thing…. COMPARE . Take this opportunity to compare between part d plans and Medicare Advantage and see which one will cover your specific diabetes medicine better.

Adriane Williams · Answer

A part D prescription plan and a Medicare plan with prescription drug coverage is the same. Each company formulary is different. We can review if you like.

Bobby Coates · Answer

Whether you chose standalone Part D (Original Medicare) or an Advantage Plan, it is important to remember there is no such thing as a plan that covers ALL medications. Each plan (PART D standalone or Advantage) will have its own special list (Formulary) of medications it will cover. The plan will break down the medications into tiers and that is what will determine your Co-Pay if any. I would recommend meeting with an independent agent and having them do a review to determine the best option. If you are new to Medicare you may be able to sign up now. Otherwise you will want to wait until AEP (October 15-December 7).

Answered by Bobby Coates on April 10, 2025

Agent Licensed in TX, AL, AZ & 21 other states

Answered by Bobby Coates Medicare Insurance Agent

Daniel Keenan · Answer

If your goal is Drug coverage, your only requirement is that you have enrolled in Part B. You then can enroll in Part D during enrollment periods. Getting MAPD also adds extra benefits for you along with great medical benefits.

Answered by Daniel Keenan on June 8, 2025

Broker Licensed in FL

Answered by Daniel Keenan Medicare Insurance Agent

Barbara Klie · Answer

Choosing between a standalone Medicare Part D plan and getting prescription drug coverage through a Medicare Advantage plan can be a significant decision, especially if you have expensive diabetes medication. Here are some factors to consider when making your choice:
1. Coverage Options
  ◦  Standalone Part D Plan: This option is specifically designed to provide prescription drug coverage. You can choose a plan that best fits your medication needs and budget. Standalone plans can vary significantly in terms of premiums, deductibles, and copayments for different medications.
  ◦  Medicare Advantage Plan (Part C): Many Medicare Advantage plans include prescription drug coverage (MAPD). This can be convenient as it combines your medical and drug coverage into one plan. However, the formulary (list of covered drugs) may differ from standalone Part D plans.
2. Formulary and Cost
  ◦  Check the Formulary: Regardless of which option you choose, it’s crucial to check the formulary of the plan to ensure that your specific diabetes medications are covered. Some plans may have different tiers for medications, which can affect your out-of-pocket costs.
  ◦  Cost Considerations: Compare the total costs, including premiums, deductibles, and copayments for your medications under both options. Sometimes, a standalone Part D plan may offer better coverage for specific medications, while other times, a Medicare Advantage plan may be more cost-effective.
3. Network Restrictions
  ◦  Provider Networks: Medicare Advantage plans often have provider networks, which means you may need to use specific pharmacies to get the best prices on your medications. Standalone Part D plans may offer more flexibility in choosing pharmacies.
  ◦  Access to Specialists: If you have a diabetes specialist or a specific healthcare provider you prefer, check whether they are in-network with the Medicare Advantage plan you are considering.

Eva Peterson · Answer

Different carriers cover differently so you should review your meds with a broker. This is at no cost to you ever and I’m happy to work with you to help you make the right choice. Contact me, Eva Peterson, 4089640345. Looking forward to speaking with you!

Answered by Eva Peterson on April 14, 2025

Agent Licensed in CA, FL & NV

Answered by Eva Peterson Medicare Insurance Agent

My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website