What Drugs Does Medicare Part D Cover, and What If Mine are Not Covered?

Posted in Medicare Part D

For many seniors, regular prescription drug use is an important part of maintaining health and vitality. We take medicine to control high blood pressure, help ensure a healthy heart, and even to help us get a good night’s sleep. If you rely on medication to be your best, you probably want to know which Medicare Part D plan offered through Medicare is a smart choice.

Will Part D cover your medications? What if it doesn’t, do you have any options? While every plan is different, most plans follow the same general structure. Here’s a quick look at what you can expect.  

Part D Coverage Requirements 

Medicare requires that all Prescription Drug plans cover certain types or classifications of drugs. For instance, cancer drugs or those prescribed to help depression are almost always covered. The majority of drugs in the following 6 classes are typically covered:

  1. Anti-depressants
  2. Ant-convulsants
  3. Anti-psychotics
  4. Immunosuppressants
  5. Cancer drugs
  6. HIV/Aids drugs

Understanding Formularies, Tiers and Plan Rules 

Every Part D plan has a unique formulary, or list of covered drugs. Formularies change annually, and are often different from plan to plan, which is why it’s so important to make sure your medication is covered on your plan’s formulary.

Tiers represent different levels of drugs. In general, drugs in lower tiers are less expensive than drugs in higher tiers. For instance, many generic drugs are categorized as tier 1, while brand name versions of the same drug are often in tier 2 or 3. Tier 4 often includes costly specialty drugs.

Most plans have rules and coverage restrictions for certain drugs to help ensure safety and control costs. For instance, some drugs require prior authorization, meaning your doctor must contact your plan before you can fill your prescription. Quantity limits are also in place for certain drugs. Sometimes plans will only cover a 30-day supply of a certain drug, or the plan may place restrictions on the amount you can take in a certain time period.

If Your Current Plan Doesn’t Cover Your Drugs

If you have Part D, or prescription drug coverage as part of Medicare Advantage, but your medication is not covered, you have options. If the drug has been removed from your plan’s formulary, or was never included to begin with, you can ask to move to a drug that is covered. Or, you can ask your plan to make an exception, and allow you to continue to use the drug you already use.

Generally, to receive an exception, your doctor must provide a medically necessary reason for you to remain on the drug. In some cases, if you’ve already paid out-of-pocket for medication that is not covered by your plan, you may be able to get reimbursed. Note: coverage determinations do not always result in reimbursement. Be careful before paying for drugs that are not listed on your plan’s formulary—you may not be able to get your money back.

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