Medicare Part D, established in 2006, gives participants help paying for their prescription drugs. Private insurance companies develop the plans and must secure approval from Medicare before they can market them. Participants shop for drug plans primarily by searching for their own prescriptions online and finding which companies offer the best deal. Nearly three-fourths of the cost of the Part D program nationwide is subsidized by Medicare.
Part D plans must cover substantially all drugs in each of six therapeutic categories: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, immunosuppressants and anti-cancer medications. This means all molecularly unique drugs and unique dosage forms, such as oral and transdermal, must be covered.(Ref 6, sec. 30.2.5, 3rd paragraph) In addition, they are required to offer at least two drugs of their own choosing in every other category. No plan, however, will offer every drug that a physician might prescribe; Medicare participants should shop around to find a plan that offers all or most of the medications they take.
Part D plans are not required to cover medications for hair growth, weight gain or loss, erectile dysfunction, fertility or relief of coughs or colds, although some plans do offer them as an added benefit. In addition, Part D plans don’t usually cover most prescription vitamins and minerals or over-the-counter medications.
Each plan has a list of covered drugs in a list called a formulary, which usually groups drugs into three or four separate tiers. Your co-pay for a medication is based on its tier; the higher the tier, the higher the co-pay. If you’re prescribed a drug that’s not in your plan’s formulary, you’ll have to pay full cost. However, there is an exception request and appeal process that can result in a non-covered drug being added to the formulary, or in a covered drug being moved from a higher, more costly tier to a lower tier. (Ref 1, p 84, “Exception”)
Drugs Not on the Formulary
If you have a prescription that’s not on your drug plan’s formulary when you enroll, the plan should give you a 90-day supply of the drug to give you and your doctor time to identify another suitable medication in the plan’s formulary. Likewise, your doctor should try to make subsequent prescriptions from your plan’s formulary. In either case, if you wind up with a prescription that’s not on your plan’s formulary, you can request an exception by submitting a statement of medical necessity from your doctor. If your request is denied, you can file an appeal.
How to Select the Best Drug Plan for You
The best way to select a drug plan is to use Medicare’s interactive Part D Plan Finder because it compares all the plans available in your area. After you provide information about your location, your Medicare plan and your prescriptions, the system will give you a list of plans available in your area together with information about each plan, including whether all your drugs are in the company’s formulary, your monthly premium, and an estimate of your annual out-of-pocket cost.
- Part D drug plans typically cover self-administered medications. Medications delivered in a hospital are covered by Part A. Those administered in a doctor’s office -- such as chemotherapy, vaccinations and certain oral cancer medications, are covered by Medicare Part B, as are certain blood glucose testing supplies for people with diabetes.
- Although you can enroll in a drug plan directly from Medicare’s Plan Finder, it’s prudent to contact the insurance company offering the plan and confirm costs and coverage for your medications.
- Centers for Medicare and Medicaid Services: Your Guide to Medicare Prescription Drug Coverage
- California Health Advocates Blog: Learn What Drugs are Covered Under Medicare Parts A, B, and D
- Medicare Interactive: Drugs that are excluded from Medicare coverage
- Kaiser Family Foundation: The Medicare Prescription Drug Benefit Fact Sheet
- Centers for Medicare Services: Medicare Prescription Drug Benefit Manual, Chapter 6
- Horsche/iStock/Getty Images