Most prescription drugs that are not covered under Medicare Part A or Part B are included in Medicare Part D coverage. Generally, that means any drug that requires a prescription and is approved by the Food and Drug Administration--and that Medicaid lists in its drug coverage--is included. However, Part D plans, which are sold by private companies, are not required to pay for all covered drugs. Before you decide on a Part D plan, check the plan's formulary (drug list) to make sure your prescriptions will be covered.
Make sure your prescription is covered by your Part D plan.
Parts A and B
Medicare Part A pays for drugs provided and administered during a qualifying stay at a hospital or skilled nursing facility. The drug coverage is included in the Part A payment made to the facility. Medicare Part B covers drugs that typically are not self-administered and are given to you by a licensed health-care professional. As a general rule, that means drugs provided through injection or infusion. If a doctor determines it is unreasonable to expect a patient to administer the drug, it is eligible for Part B coverage. Part B also covers immunizations, including one shot per flu season and a pneumonia vaccination. Before a drug can be submitted as a Part B expense, you generally must fulfill the Part B deductible. In many cases, the portion of the drug not paid for by Part B will be covered by Medigap policies.
Part D Formulary Guidelines
The law that established Part D set up the general guidelines for the drugs that are covered. The law also established the rules by which companies could leave drugs off their formularies. To exclude a drug, the Centers for Medicare and Medicaid Services (CMS) must determine that the company is not trying to discourage a particular group or class of persons from enrolling. Generally, companies will exclude some brand drugs for which there is a somewhat comparable generic drug available. In some cases, companies will institute a "step" process, in which a brand drug is covered only after other drugs have been tried.
Keep in mind that plans can change their formularies at any time if the change passes the non-discrimination test and all plan participants are given 60-day notification of the change. It's worthwhile to run a check on available Part D policies each year during the annual open-enrollment period, from November 15 to December 31 (see Resources below). A plan that you previously rejected only because of its drug list might have changed its formulary, making it more advantageous for your needs.
Drug Tiers
Prescriptions covered by Part D plans are grouped within the formulary. The grouping assigned to the drug provides a general description of the level of coverage within the plan. Most Part D plans have four tiers: preferred generics; preferred brands; non-preferred generics and brands; and specialty drugs.
Class Exclusions
Certain classes of drugs are specifically excluded from Part D coverage, including the following: fertility drugs; weight-loss or weight-gain drugs; any drugs taken for cosmetic reasons; drugs to relieve common colds and coughs; vitamin and minerals, even those taken by prescription; over-the-counter drugs, including those that must be purchased through a pharmacist; and barbiturates and benzodiazepines. Insulin and smoking-cessation drugs are not excluded.
The excluded classes most problematic for Medicare recipients are weight-gain drugs, which often are used for cancer and HIV patients; barbiturates and benzodiazepines, which are prescribed to control anxiety and seizures in older patients as well as extreme muscle spasm in cerebral palsy patients; and over-the-counter drugs, which often are used by nursing-home residents.
Exceptions Process
Any Part D drug plan approved by the CMS must have a posted process through which plan participants can ask the company to cover a non-formulary drug or to provide additional coverage for a brand drug included on the formulary. By making this kind of request, you're basically asking the company to apply its formulary guidelines to all plan participants except you, so these requests are rarely approved. It's better to make sure your prescriptions are included in the plan's formulary before enrolling in the plan.
Both the Medicare Part D home page and Q1Medicare.com have online tools for screening formularies (see Resources). Check to see if your prescriptions require prior authorization or are subject to a step process.
Pharmacy Discount Plans
Drugs included as part of a retail pharmacy's discount plan also can be covered by a Part D plan. First check the list of drug providers allowed by your Part D plan. If your preferred pharmacy is included, you may well benefit from staying in that store's discount plan (for example, stores that sell some generic drugs for $4 or $5).
If you have a Part D plan that charges you a 25 percent co-pay and your drug is part of the discount program, you will pay $4 for the prescription until you meet your deductible, then you will pay only $1 through the covered portion of the plan. In addition, the lower total cost will delay pushing you into the uncovered portion of your Part D drug plan. Generally, such discount programs cover only drugs purchased at a retail outlet.
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