Prescription Drugs, Medical Supplies & Equipment
Not all health plans cover prescription drugs. If your plan does, usually your membership card will list your co-pays.
Each plan also has different benefits coverage for medical supplies and equipment. Medical supplies are things like syringes and bandages. They are used once or a few times. Durable medical equipment, or DME, is used again and again, and includes things like walkers, respirators, and wheelchairs.
Topics on this page:
- Your plan usually has a formulary. This is the list of preferred drugs.
- If you want a drug that is not on this list, you must get pre-approval or pay for it yourself.
- Several times a year, the formulary is reviewed and may change. A new drug or a generic version of a drug may be added. Or a drug may be removed because new research has shown that the drug has a dangerous side effect.
- If your medicine is taken off the formulary, but you and your doctor think you still need it, your doctor can ask the plan to keep covering it for you.
- Learn how to use prescription medicines safely.
- If you have prescription drug coverage, you must get prescriptions filled at a pharmacy in your plan’s network.
- Compare prices at different pharmacies.
- Ask if the pharmacy has a computer program that keeps track of all the drugs you take. This can help you avoid problems with drug interactions.
- If you have Medicare, you get your prescription drug coverage in one of two ways: Through your Medicare Advantage health plan (Part C) or through a separate Medicare prescription drug plan (Part D). Learn more...
- Learn how health care reform is ending the "donut hole."
- Health plans must cover many diabetes supplies. They also cover asthma supplies for children.
- Benefits for other supplies and equipment vary from plan to plan. Ask your doctor or your plan.
- Health plans do not have to cover most DME. If they do cover DME, they only pay for equipment you medically need, like a wheelchair if you cannot walk or oxygen if you have trouble breathing.
- You may have to pay part of the cost.
- You have to get prior approval from the plan before you get the equipment.
- Before you join a plan, ask if it covers the equipment you need and what the cost is.
- There may be a limit on what your plan will pay for equipment. For example, a plan may pay up to $2,000 a year.
- You must use providers in your plan’s network.
- If you need equipment, your doctor may refer you to a rehabilitation clinic for an assessment. The clinic will write a report on your problem, with a recommendation for specific equipment. Your doctor submits the report to your plan with the request for approval.
- If a request for supplies or equipment is not approved, your doctor can submit it again, with more information to justify it. You can also file a complaint.
OPA materials: How to Use Your Health Plan Guide
OPA materials: California's HMO Guide for Seniors
Department of Managed Health Care - Information on health plan coverage for prescription drugs and durable medical equipment
U.S. Food and Drug Administration - Information for consumers on prescription drugs and medical devices
Prescription drug costs
Using medicines safely