Medicare Part D plans offer you a way to control the cost of prescription medications. Before Part D was introduced in 2006, Medicare recipients generally paid the entire cost of their medications or bought Medicare supplements that at the time had a very limited amount of drug coverage. What Part D covers now provides us with a much better solution.
What Medicare Part D covers
Part D prescription drugs
Part D plans have huge formularies of medications to treat many different illnesses and conditions.
Medicare Part D allows for coverage of most retail prescription drugs in the United States. Each plan maintains a list of medications, or formulary, that it covers. Medicare requires that the plan must offer at least 2 drugs in each therapeutic class. Also, they cover all or substantially all drugs in six categories. Those categories are antidepressants, antipsychotics, anticonvulsants, immunosuppressants and anti-cancer.
These requirements mean that any drug plan you enroll in will have many medications to treat you for future illnesses.
Part D drug plans also cover many common vaccines, such as the shingles vaccine, to prevent illness.
There are a few types of medications that Medicare does not require drug plan carriers to include in their formularies. These are:
Barbituates – sedatives or other drugs that depress the central nervous system
Benzodiazepines – commonly prescribed for insomnia or anxiety
Fertility or erectile dysfunction medications
Drugs for cosmetic reasons, such as hair growth
Drugs for weight loss, weight gain, or anorexia
Prescription strength vitamins and minerals
Cough syrups or other meds that treat cold symptoms
Compound medications – Part D plans typically do not cover compounded medications. If you take a dose of a medication that is different from the standard dosage, that requires compounding, then typically you will pay the retail price for that medication.
For these exceptions, you may occasionally find a Part D drug plan carrier that offers the drug anyway. However, that is their choice to do so, and each year when the drug plan is re-filed with Medicare, the medication can be removed from the formulary for the next year if the insurance carrier wishes to no longer cover it.
Part B Medications
Certain types of medications fall under Medicare Part B instead of Part D. If you have original Medicare with a traditional supplement, these medications will generally be fully covered. If you have opted for a Medicare Advantage plan instead, you will pay the plan’s co-insurance as outlined in their benefit summary. Under many Medicare Advantage plans, this might be a 20% cost-share for you, but your Part B spending will count toward your plan’s out-of-pocket maximum.
The primary categories of prescriptions that sometimes fall under Part B are:
Drugs provided in a physician’s office, such as chemotherapy medications
Medications administered via durable medical equipment, such as nebulizers or internal or external pumps
Immunosuppressive meds – commonly given after an organ transplant
Some oral cancer or related anti-nausea medications that you administer to yourself
Some medications that treat End-Stage Renal Failure – an example would be Erythropoietin
Drugs delivered in a hospital outpatient care situation
Vaccines ordered by a physician, such as pneumonia or hepatitis vaccines
Blood clotting factors
Diabetes supplies – lancets, test strips, glucose monitors
Before deciding on your Medicare Part D drug plan, you will want to fully understand how Part D works and what rules and limits may apply to the plans available to you.