By Dana Barrett
Some Medicare Advantage plans provide recipients with an Over-the-Counter (OTC) quarterly or monthly benefit allowing a participant to purchase many healthcare items that don’t require a prescription and are not covered by the standard Medicare Part D program.
What are Over-the-Counter Medications?
Over-the-Counter (OTC) medications include any medication you need that doesn’t require a prescription. This can include cold-medicines like Mucinex, pain relievers such as Advil and Tylenol, and digestive aids like Tums or Pepto-Bismol. Also, multi-vitamins, suppositories, cough drops, and even Neosporin frequently fall under the OTC umbrella.
Eligible OTC Plan Purchases
As mentioned, Medicare Advantage OTC benefits are used to purchase health-related items and medications approved by your Medicare Advantage Plan. In addition to medicine, these plans frequently cover additional health care items such as:
- First-aid kits
- Dental floss
- Blood pressure kits
- Contact lens solution
- Sleep aids
- Products for acne care
- Orthopedic support devices
- Denture cleaning products
- Ear care items
Of course, every OTC plan is unique so it is important to check with your insurance carrier or Medicare Advantage provider to find out which items are covered with your plan.
How an Over-the-Counter Benefit Plan Works
If you are enrolled in a Medicare Advantage Plan that includes OTC coverage you will have a quarterly or monthly benefit amount to spend on over-the-counter items. The plan benefit can be anywhere from $10 to $150 per period and it’s essential to ensure that the things you buy are only those items that are included in the your specific Medicare Advantage Plan. When you make a purchase, the cost is deducted from the quarterly or monthly total. Once you have reached the maximum benefit for the plan in each period, the plan benefit cannot be used again until it’s reloaded for the next period.
Medicare Advantage Flex Card Program
Is an OTC Plan the same as a Medicare Advantage Flex Card? The answer is not exactly. There are Medicare Advantage Plans that distribute OTC benefits via a prepaid point-of-sale card referred to as an OTCNetwork card. This card only covers the participant’s OTC benefit and nothing more.
The Flex Card, however, is a Visa debit card that is offered by some Medicare Advantage Plans primarily to help pay out-of-pocket expenses for dental care, vision, and hearing care that exceeds your Advantage plan benefits. There are some insurance carriers who use the Flex card for both dental, vision, and hearing benefits as well as managing a participant’s OTC purchases.
Here’s an example of how a Flex Card is used: Let’s say your Medicare Advantage Plan coverage limit for eyeglass replacement is $200, but the actual cost of the glasses (with prescription lenses) is $325. You can use your Flex card to pay the difference.
A Flex Card is delivered to you pre-loaded with the specific dollar amount included with your Medicare Advantage Plan. The plan amount could be anywhere from $200 – $2,000 and that amount is intended to cover the whole year. One of the main benefits of a Flex card is that you have the “flexibility” to choose which eligible services you would like to pay for with the card balance.
How to Use your OTC Medicare Advantage Benefits
The insurance carrier who provides your Medicare Advantage Plan will send you a catalog each calendar year that includes all the items that are eligible OTC purchases. You can order your items directly from the catalog by filling out an order form or you can call to order them over the phone. Some Advantage plans even have a website for online orders. If you have an OTCNetwork card, you can pick up available items at participating retailers. Here is a list of some of those retailers:
- Rite Aid
- Duane Reade
- Dollar General
Medicare Advantage cards may work at other retail stores based on your plan’s coverage. You can check with your plan provider, insurance carrier or just go on to the OTCNetwork.com for a complete list of stores.
Is SPAP Similar to a Flex or OTC Program?
SPAP stands for State Pharmaceutical Assistance Program. These medication assistance programs are offered at the state level to help low-income seniors pay for prescription drugs. SPAP is a different plan from the OTC benefits program in that SPAP only covers medications that are prescribed and SPAP is not offered as part of a Medicare Advantage Plan.
SPAP’s have eligibility requirements that differ based on the rules of the state providing the program. Some state SPAP plans require that you be enrolled in Medicare Part D to qualify for assistance. If you are enrolled in an SPAP that requires Medicare Part D and are taking a prescription drug covered by both your SPAP and your Part D plan, then the amount you pay out-of-pocket combined with the portion that SPAP pays, both count toward your out-of-pocket maximum for the year.
There are also SPAP plans that limit eligibility to only those with chronic conditions or individuals who are HIV+. SPAP’s are not available in every state, only 17 states currently offer these prescription drug assistance programs. If you are not currently receiving Medicare prescription help but would like financial assistance with drug expenses, you can check Medicare.gov to see if your state currently offers an SPAP program and review the benefits and eligibility requirements.
Medicare and Medicare Advantage offer different options for assisting low-income or fixed-income seniors with their medical needs. Medicare Part D is a standard prescription drug plan that doesn’t cover 100% of your health-related needs.
Medicare Advantage Plans can include OTC and Flex Card benefits to help pay for over-the-counter medical items, as well as extra expenses associated with eye care, hearing, and dental care. SPAP plans offered by some states are an additional payment assistance option that can offset the cost of prescription medications for those who qualify.