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Home > Drugs, Supplies & Equipment

Prescription Drugs, Medical Supplies & Equipment

Woman at pharmacy counterNot 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:

 

If you have prescription drug coverage

  • 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.

 

Choosing a pharmacy

  • 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.

 

Medicare and prescription drug coverage

  • 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."

 

Coverage for medical supplies and equipment

  • 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.

 Senior woman in a wheelchair

Getting the supplies and equipment you need

  • 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.

 

Resources

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

 

Related Topics

Prescription drug costs

Using medicines safely

Disability Assistance

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