Your plan’s drug copayments may vary between standard and preferred network pharmacies, but copays at the same national pharmacy should remain consistent as you travel. For example, if you visit a CVS pharmacy in Ohio and have a fixed $30 copay for a specific medication, then you will have a $30 copay for the same medication at a CVS in California.
Example: Copayment prices can vary between standard network pharmacies and preferred network pharmacies.
Here is an example showing how copayments can vary between preferred and standard network pharmacies using the 2024 California SilverScript Choice (PDP) plan:
| California SilverScript Choice (S5601-064) | ||||||
| 30-Day Supply Cost-Sharing | 90-Day Supply Cost-Sharing | |||||
| Preferred Pharmacy | Standard Pharmacy |
Mail-Order | Preferred Pharmacy | Standard Pharmacy |
Mail-Order | |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1 - Preferred Generic: | $2.00 | $8.00 | $2.00 | $6.00 | $24.00 | $6.00 |
| Tier 2 - Generic: | $7.00 | $15.00 | $7.00 | $21.00 | $45.00 | $21.00 |
| Tier 3 - Preferred Brand: | 16% | 16% | 16% | 16% | 16% | 16% |
| Tier 4 - Non-Preferred Brand: | 36% | 36% | 36% | 36% | 36% | 36% |
| Tier 5 - Specialty Tier: | 25% | 33% | 33% | n/a | n/a | n/a |
Note: The preferred and standard network pharmacy cost-sharing can vary by state. You can use our Rx$ icon on our PDP-Finder or MA-Finder to see the cost-sharing details for all tiers and pharmacies for any Medicare Part D or Medicare Advantage plan with prescription drug coverage.
Bottom Line #1: You should pay the same fixed copays as you travel across country, but copays can vary between standard and preferred network pharmacies.
The good news is that you probably will have no problem finding one of your Medicare plan's preferred network pharmacies as you travel. Most Medicare prescription drug plans include more than 50,000 to 60,000 pharmacies in their network - and, as you travel, you can always call your Medicare Part D plan to find a nearby preferred network pharmacy - the toll-free number for your Medicare Part D plan's Member Services department is found on your Member ID card. If your Medicare Part D plan is using coinsurance (you pay a percentage of retail, such as 25% of the retail drug cost), you may find that, since retail drug pricing can vary between different pharmacies across the country – and retail drug prices can change over time – your formulary drug cost can also change.
For example, if you pay a fixed 25% of the $80 retail price for your Tier 3 medication in Ohio, then 2-months later, you may find that you are now paying 25% of the $100 retail price in California for the same medication. In other words, the retail price of your medication increased during the two months and you are now paying $25 for your Tier 3 medication instead of the earlier $20.
Example: Retail drug prices vary slightly pharmacy-to-pharmacy and can change over time.
Here is a short example from 2016 using three popular brand-name medications and two different network pharmacies in three different states (for this example Medicare Part D plan, CVS pharmacy has "Standard Cost Sharing" and Walmart pharmacy has "Preferred Cost Sharing").
As you can see we are actually comparing three different 2016 "AARP MedicareRx Preferred (PDP)" Medicare Part D plans in three different regions to show that retail drug prices can stay consistent across the country - although retail prices can vary slightly between different network pharmacies.
|
2016 AARP MedicareRx Preferred (PDP) |
||||||
| Example Drugs |
(S5820-013-0) 44319 (Summit, Ohio) |
(S5820-031-0) 90001 (Los Angeles, California) |
(S5820-010-0) 33034 (Miami-Dade, Florida) |
|||
| CVS (standard) |
Walmart (preferred) |
CVS (standard) |
Walmart (preferred) |
CVS (standard) |
Walmart (preferred) |
|
| Advair Diskus 250/50 |
$336.50 |
$334.97 |
$336.50 | $334.97 | $336.50 |
$334.97 |
| Crestor 10MG |
$249.96 |
$248.85 |
$249.96 | $248.85 | $249.96 |
$248.85 |
| Januvia 100MG |
$365.40 |
$363.73 |
$365.40 | $363.73 | $365.40 |
$363.73 |
(Source: Medicare.gov Plan Finder 07/12/2016) Also see our 2016 Medicare Part D plan Archive
Here is the same example with 2018 retail price data (and the addition of a generic equivalent). Please note the change in the drugs' negotiated retail drug prices over these two years. On a positive note, again we see that retail drug prices can remain consistent as you visit the same pharmacy (preferred network pharmacy (example: Walmart pharmacy) or standard network pharmacy (example: CVS pharmacy)) located in different parts of the country.
|
2018 AARP MedicareRx Preferred (PDP) |
||||||
| (S5820-013-0) 44319 (Summit, Ohio) |
(S5820-031-0) 90001 (Los Angeles, California) |
(S5820-010-0) 33034 (Miami-Dade, Florida) |
||||
| Example Drugs |
CVS (standard) |
Walmart (preferred) |
CVS (standard) |
Walmart (preferred) |
CVS (standard) |
Walmart (preferred) |
| Advair Diskus 250/50 |
$425.03 |
$414.81 |
$425.03 | $414.81 | $425.03 |
$414.81 |
| Crestor 10MG |
$314.07 |
$313.07 |
$314.07 | $313.07 | $314.07 |
$313.07 |
| Januvia 100MG |
$463.42 |
$452.37 |
$463.42 | $452.37 | $463.42 |
$452.37 |
| Rosuvastatin Calcium TAB 100MG (generic Crestor) |
$16.54 |
$12.11 |
$16.54 | $12.11 | $16.54 |
$12.11 |
(Source: Medicare.gov Plan Finder 06/08/2018) and see our on this site Medicare Part D Drug Finder
Bottom Line #2: Formulary prescription costs based on retail drug prices can vary pharmacy-to-pharmacy and over time.
If you travel across the country and use different network pharmacies, and pay coinsurance (such as 25% of retail), your coverage costs can vary between the different pharmacies or over time as retail drug prices change.
You can contact your Medicare plan's Member Services (the telephone number is on your Member ID card) to learn more about what you will pay as you travel.
Related Question: What happens if we permanently move to another part of the country?
If you move to another state or Medicare Part D region and leave your plan's Service Area, you are granted a Special Enrollment Period (SEP) and this SEP allows you to join a new Medicare plan (Medicare Part D or Medicare Advantage plan) in your new location.
When looking at plans available in your new area, you may find that the same Medicare Part D plans are not offered in all areas of the country - or you may find that if the same Medicare Part D plan is available, but the plan has a different formulary and cost-sharing structure that is tailored to your location.
In this case, it is possible that when you join another Medicare Part D plan in a new area, your cost-sharing for your medications can be different.
Important: Learn about your Medicare Part D plan or Medicare Advantage plan options before moving (for assistance, call a Medicare representative at 1-800-633-4227).
Related Question: How does all this apply to Medicare Advantage plans that include prescription drug coverage (MAPD)?
All of this information is applicable to stand-alone Medicare Part D prescription drug plans (PDPs) or Medicare Advantage plans that include prescription drug coverage (MAPDs).
MAPDs have a Service Area often defined only by a ZIP code (or county or partial-ZIP) and if you move to another county or city that is only a few miles from your original residence, you can find that your Medicare Advantage plan is not available or you may find that your coverage is different in the location - even when your Medicare Advantage plan has the same name or - even when you are still within the same state. In other words, you may find that you can join an MAPD with the same name, but the coverage and cost can vary in your new location.