Topics we will cover in this section:
What is Medicare Part D?
Medicare Part D covers prescription drugs, and is administrated through private insurance agencies approved by Medicare. Anyone with Medicare Parts A and B is eligible for Part D.
During open enrollment, which runs from October 15 – December 7, you can add, change, or drop a Medicare Part D plan. It is advised that you enroll in Part D even if you don’t think you need it, in order to avoid paying penalties for late enrollment later.
To save money and avoid the donut hole coverage gap, always ask your doctor if there are generic versions of the drugs you need to take, try to sign up for your plan through Medicare.gov, and only put your most expensive and brand name drugs under your Part D plan.
How Does Medicare Part D Work?
Medicare Part D helps to cover the costs of your prescription drugs. Medicare-approved private insurance companies offer Medicare Part D Prescription Drug Plans.
You can get this coverage in the form of a Medicare Advantage Prescription Drug plan (MAPD) or a stand-alone Medicare Part D Prescription Drug Plan. As long as you have Parts A and B, you can enroll in any of the Medicare Part D prescription drug plans that serve the area in which you live.
What is the Prescription Drug Formulary?
Each prescription drug plan has its own formulary, or list of drugs that it covers. Drugs in the formulary are placed in different Tiers reflecting their costs. Tier 1 is usually for generics and has the lowest cost-sharing amounts. Tiers 2 through 5 contain brand-name and specialty drugs, which generally have higher out-of-pocket cost-sharing amounts.
To find out if your plan covers your medications, you can search drugs in the 2021 drug formulary or use Medicare’s Plan Finder tool. To get the most accurate information, check your plan’s Evidence of Coverage (EOC) for all the details of what drugs it will cover.
What Part D MUST Cover
Here is what Part D is required to cover.
Medicare Part D plans MUST cover:
- HIV/AIDS treatments
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressant medications
- Anticancer drugs (unless they are covered by Medicare Part B)
In addition, Part D plans are required to cover:
- All commercially available vaccines, such as shingles and flu shot (except for those covered under Part B)
- A range of generic and brand-name drugs that are:
- Generally needed by the Medicare population
- Insulin preparations, even in states where a prescription is not required
- Available only by prescription
Always be sure to check coinsurance and copays associated with the drug and what Tier it is in.
What Part D WILL NOT Cover
There are certain drugs that Part D won’t cover. According to national Medicare guidelines, these drugs are never covered under Medicare Part D:
- Drugs for anorexia, weight loss, or weight gain (except to treat physical wasting)
- Drugs for fertility
- Drugs for hair growth or cosmetic purposes
- Drugs for cough and cold symptoms
- Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
- Non-prescription drugs
- Drugs for sexual dysfunction like Viagra and Cialis
- Non-FDA-approved drugs
- Drugs the FDA has determined to be safe but not effective – evaluated by the FDA’s Drug Efficacy Study Implementation (DESI)
- Bulk chemicals
- Devices like diaphragms
- Ingredients/adjuvants, like sterile water for injection
- Line flush, like normal saline IV flush
- Medical supplies
- Drugs covered by Medicare Part A or Part B
Some of the drugs listed above may be covered by Part D if they are prescribed to treat other conditions, as long as they have been approved by the FDA for that treatment.
Drugs Covered by Parts A and B
Some drugs are covered by Part A or B in special circumstances. Part A will cover drugs needed during a hospital or skilled nursing facility stay. Part B covers some prescription drugs in limited circumstances, such as oral cancer drugs you are given in a doctor’s office or hospital.
Exceptions and appeals
If your plan doesn’t cover a drug that you need, you have the right to ask for an exception or request an appeal if you disagree with your plan’s decision.
Also, don’t forget to ask your prescriber if there’s a generic, over-the-counter, or less expensive version of the drug you can take.
Sometimes, Part D plans make changes to their formulary throughout the year. If these formulary changes affect a drug you are taking, your plan must:
- Provide notice in writing 60 days before the change goes into effect.
- When you request a refill, your plan must provide written notice of the change and a 60-day supply of the drug under the same plan before the change.
Part D Plan Coverage Rules
Each Part D plan comes with its own rules for coverage. Some of those rules may include:
- Prior Authorization
For certain prescriptions, you and/or your doctor may need to contact your plan to prove that the drug is medically necessary before the prescription can be filled.
- Quantity Limits
Sometimes there will be limits of how much of a medication you can get at a time.
- Step Therapy
Sometimes you must try one or more similar, lower-cost drugs before your prescribed drug will be covered.
Also, you drug plan will perform safety checks, such as checking for unsafe amounts of opioids.
You can ask for exceptions to these rules if you believe one or more of these rules should be waived.
Drugs in Outpatient Hospital Settings
Some drugs that you take in an outpatient setting like an emergency room (that you would normally take on your own) may be covered by Part D. You will need to pay out-of-pocket, and then your Medicare Part D plan will reimburse you after you submit a claim.
To find a Medicare Part D plan, use Medicare’s Plan Finder.