What Medicare Part D Covers

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 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, anti-cancer medications and HIV/AIDS drugs.

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:

  • 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 loss.

  • 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.