What Part D MUST Cover

What Part D Must Cover

We recently listed the drugs Part D will not cover. Now let’s look at a list of what Part D is required to cover.

According to the National Council on Aging, Medicare Part D plans MUST cover:

  • HIV/AIDS treatments
  • Antidepressants
  • 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 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. Plans can also impose limits on the use of certain drugs, through authorization rules, quantity limits, and step therapy (in which the plan requires the patient to try another, less costly drug for up to 90 days first).

What is the Prescription Drug Formulary?

Prescription drugs are listed in a formulary of which drugs are covered by insurance each year, and categorized in different Tiers based on how much you will have to pay. Tier 1 is usually for generics and has the lowest cost-sharing amounts. Tiers 2-5 contain brand-name and specialty drugs, which generally have higher out-of-pocket cost-sharing amounts.

You can search drugs in the 2017 drug formulary here. To get the most accurate information, check your plan’s specific formulary. The National Council on Aging offers more details on what is and isn’t covered under Part D.

Related Links

What Part D Will Not Cover

What is Part D, and Do I Need It?

New Part B Premium Brackets for Higher Income Beneficiaries

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