What Is and Isn’t Covered

Medicare Part D plans are a way of lightening the financial burden of prescription medications. Without a Part D plan, people would pay all their medication costs out-of-pocket.

Medicare Part D covers most retail prescription drugs in the U.S.. Each plan has a formulary, which lists which medications they cover. Medicare requires that plans offer at least 2 drugs in each therapeutic class. Furthermore, they cover drugs in six major categories. Those categories are antidepressants, antipsychotics, anticonvulsants, immunosuppressants, and anti-cancer.

Part D drug plans also cover some common vaccines, like the shingles vaccine.

Medicare does not require drug plan carriers to include the following medications in their formularies:

  • Barbiturates – 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 isn’t 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 decision to do so, and each year when the drug plan is re-filed with Medicare, the medication may be removed from the formulary for the next year if the insurance carrier chooses to no longer cover it. That is why it is important to check your plan’s formulary at the beginning of every year.

Part B Medications

Certain types of medications fall under Medicare Part B instead of Part D. If you have Original Medicare with a supplement plan, 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 described in their benefit summary. Under many Medicare Advantage plans, this might be a 20% cost-share, 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, such as those given after an organ transplant
  • Some oral cancer or related anti-nausea self-administering medications
  • Some medications that treat End-Stage Renal Failure, such as 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, such as 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 or limits may apply to the plans available to you.