Getting care
Ask what your plan will actually pay.
Match the exact medicine and use
In September 2026, Medicare’s basic prescription benefit excluded medicines used for weight management; the reason for the prescription could change whether payment was possible. Medicare’s coverage information
For example, use for type 2 diabetes could qualify for coverage, even when use for weight loss would not.
That possibility is not a coverage promise; the plan’s drug list and approval process still apply. Medicare’s conditions for coverage
Ask your plan about the named product and the reason it is being prescribed.
Understand prior authorisation
Prior authorisation puts the payment decision with the insurer before a prescription is filled through the plan. Coverage and plan approval
- Is the exact product on my plan’s list?
- Who sends the required information?
- What will I owe if the claim is refused?
Keep cash payment separate
Cash self-pay offers bypass insurance; the September 2026 terms excluded these payments from plan deductibles and yearly out-of-pocket limits. The government-listed self-pay offer
The deductible is your spending threshold before a plan starts sharing costs under its rules. Ask your plan to explain its terms before comparing prices.