What is Medicare?

Abarca has deep experience serving public and private sector organizations, including Medicare and Commercial Health Plans, Self Insured Employers, State Medicaid Programs, and Large Insurers and PBMs. We understand the Medicare patient’s unique needs and have been recognized and rewarded for our expertise and ability to serve them. So, what exactly is Medicare?

Medicare is the federal health insurance program for:

  • People 65 or older 
  • Certain younger people with disabilities
  • People with end-stage renal disease

Medicare coverage is based on 3 main factors:

  • Federal and state laws.
  • National coverage decisions made by Medicare about whether something is covered.
  • Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

 The different parts of Medicare help cover specific services:

  • Medicare Part A or Hospital Insurance covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some homecare.  
  • Medicare Part B or Medical Insurance covers certain doctors’ services, outpatient care, medical supplies, and preventive services. 
  • Medicare Part D or prescription drug coverage covers the cost of prescription drugs, including many recommended shots or vaccines.

 So how does Medicare work? 

  • Once you enroll, Medicare offers two main ways to receive your coverage: Original Medicare (made up of Part A and Part B) or Medicare Advantage (sometimes called Part C). Most people don’t pay a monthly premium for Part A. If, in your case, you don’t qualify for premium-free Part A, you can have the option to purchase Part A. However, everyone pays a monthly premium for Part B. 
  • Medicare drug coverage helps pay for prescription drugs you need. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage. This includes Medicare drug plans and Medicare Advantage Plans with drug coverage. 
  • Each plan can vary in cost and specific drugs covered but must give at least a standard level of Medicare coverage. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.
  • Plans have different monthly premiums. You’ll also have other costs throughout the year in a Medicare drug plan. How much you pay for each drug depends on which plan you choose.

 2 ways to find out if Medicare covers what you need:

  • Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that’s usually covered but your provider thinks that Medicare won’t cover it in your situation. If so, you’ll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
  • Find out if Medicare covers your item, service, or supply.


At Abarca, we are constantly monitoring Medicare annual changes so that our Darwin system is up to date with regulatory and clinical enhancements –an example is the Annual CMS Call Letter. We want to make sure our Darwin platform can process changes needed so that the patient, pharmacy, and member has a seamless experience.

As part of our unrelenting commitment to providing a better way in healthcare, our team will continue to educate on Medicare-related topics so that Medicare patients and their caregivers can make informed and up to date decisions on their care. Stay tuned for the next blog post in our Medicare series. 

This blog was written by Ana M. Rivera, PharmD, Clinical Programs Manager at Abarca. Information on the programs’ details was retrieved from https://www.medicare.gov/.

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