Medicare Supplements

Medicare Part D is an insurance plan that provides prescription drug coverage for Medicare beneficiaries.

There are only two ways to get this coverage:

 

  1. Through a standalone plan

  2. It comes along with your Medicare Advantage plan

What does Medicare Part D cover?

Each Part D plan has a list of drugs that are covered called a formulary.

Drugs are broken down into different tiers on formularies. In most cases, drugs in the lower tiers have a lower out-of-pocket cost. 

Here is an example from Medicare.gov that shows how a tier may look (yours may be very different):

  • Tier 1—lowest copayment : most generic prescription drugs

  • Tier 2—medium copayment: preferred, brand-name prescription drugs

  • Tier 3—higher copayment: non-preferred, brand-name prescription drugs

  • Specialty tier—highest copayment: very high cost prescription drugs

 

Medicare requires each plan to cover all — or at least most — drugs in these classes:

  • Antidepressants

  • Antipsychotics

  • Anticonvulsants

  • Immunosuppressants

  • Anti-cancer medications

  • HIV/AIDS drugs

 

Every plan also covers most common vaccines that prevent illness.

If your doctor thinks you need a drug on a higher tier rather than one that is in a lower tier, you can file an exception and ask your Part D plan provider for a lower copayment.

You also have the right to ask for:

  • Explanation about your plan’s benefits

  • An exception if a drug you need is not covered by your plan

  • Exception to waive coverage rules

Your plan’s coverage can change but there are rules

If your plan’s provider makes any changes to your formulary, the company must publish changes to the plan’s website.

They must also tell you in writing if drugs are removed from your formulary.

All plans are restricted from making changes to the drugs provided or price changes between the beginning of the annual election period until 60 days after coverage begins.

The only exception is if the FDA says a drug is unsafe or the manufacturer simply stops making the drug.

If changes are made, the insurance company must include in its notice:

  • The name of the drug

  • If the drug changed tiers

  • The reason for the change

  • Alternate drugs available

  • Any cost sharing 

  • If exceptions are available

Drugs that are not covered

Each plan could have different drugs that are covered. But, there are some drugs that are not covered under any Part D plan.

Generally, these are drugs for:

  • Weight loss

  • Weight gain

  • Fertility

  • Erectile dysfunction 

  • Any over-the-counter medication

 

Also, if your Part A or B plan is providing coverage, Part D does not kick in additional payment.

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Disclaimer

Medicare has neither endorsed nor reviewed this information.

Not connected or affiliated with any United States Government or State agency.

 

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