In simple terms, Medicare Part D plans offer you a way to control the cost of prescription medications. Choosing a Medicare Part D plan may seem easy but many many seniors are confused by what the correct choices are and how they coordinate with their medications. The last thing you want to happen is having to switch plans because you were put in the wrong plan. The worst thing that can happen is you get enrolled in a plan but you won’t realize it’s the wrong plan until you use it. Hence, you are stuck with the plan and the out of pocket costs until you can change out of it once a year during the Annual Enrollment Period that happens from October 15th thru December 7th.
Drugs covered under Medicare Part D
Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans cover all commercially available vaccine drugs when medically necessary to prevent illness. Otherwise, the plan decides which drugs to cover, which drugs not to cover, and under which tier to cover them.
Before enrolling in a Medicare Prescription Drug Plan or Medicare Advantage plan that includes drug coverage, you should review the plan’s formulary to see which drugs it covers. 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.
Drugs not covered under Medicare Part D
Since each Medicare Part D Prescription D plan decides which drugs not to cover on its formulary, the list here is not complete. However, plans usually do not cover:
- Weight loss, weight gain drugs or anorexia
- Drugs for cosmetic purposes or hair growth
- Fertility drugs
- Drugs for sexual or erectile dysfunction
- 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.
- Barbiturates – sedatives or other drugs that depress the central nervous system
- Prescription strength vitamins and minerals
- Benzodiazepines – commonly prescribed for insomnia or anxiety
- Over-the-counter drugs
Medicare Part D also does not cover any drugs that are covered under Medicare Part A or Part B.
There is very limited prescription drug coverage under Medicare Part B. Part B generally covers medications given by injection or infusion, either at home by a home health provider or in an outpatient setting such as a doctor’s office or emergency department.
For example, if you go to the doctor because you were bitten by a dog, your doctor may order antibiotics to prevent infection as well as the rabies shot. If you get a rabies injection during the visit, Medicare Part B typically covers it. If the doctor prescribes oral antibiotics for you to take at home, Part B would not pay for your medications.
Medicare Part B also pays for prescription drugs used with durable medical equipment such as a nebulizer machine or infusion pump. If you have lung disease and need nebulizer treatments at home twice a day, Part B covers the medications that go in the machine. On the other hand, if you use a hand-held inhaler for your lung disease, it is typically not covered.
Here are some of the primary categories of prescriptions that sometimes fall under Part B:
- 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
If Medicare Part B covers your prescription drugs, you pay 20% of the Medicare-approved amount after you meet your annual Part B deductible.
At Nevada Medicare we can make it easy for you – call us for a hassle-free help in understanding your benefits and what’s available to you. Contact Us today.
Most Medicare Advantage plans include Medicare Part D prescription drug coverage. Medicare Advantage plans may be more cost-effective because you generally have just monthly premium and one deductible for all covered services instead of separate premiums and deductibles for Part A, Part B, and Medicare Part D.
Keep in mind, you continue to pay your Medicare Part B premium even if you enroll in Medicare Advantage. There may be an additional monthly premium paid directly to your plan, although there may be a $0-premium Medicare Advantage plan available in your area.
Moreover, Medicare Advantage has a maximum out-of-pocket limit, protecting you from catastrophic medical bills. Once you spend the plan limit on health care and prescription medications, the plan pays 100% of covered costs. In 2019, the maximum Medicare Advantage out-of-pocket cap was $6,700, although many plans set their cap below the Medicare maximum.
Simply put, although Medicare Part B may cover limited prescription drugs, you probably want Medicare Part D through a stand-alone plan or a Medicare Advantage plan to cover most prescription drugs you take at home.
Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan beneficiaries have the right to:
- Receive “coverage determination” — a written explanation from your plan about your benefits, including how drugs are covered, your costs for drugs, any coverage requirements (such as drugs that require the plan’s prior authorization, and requirements for making coverage exceptions.
- Ask for exceptions to drugs not covered by your plan’s formulary.
- Ask for exceptions to waive plan coverage rules (like prior authorization).
- Ask for a lower co-payment for higher-cost drugs if you or your prescriber believe you cannot take any of the lower-cost drugs for the same condition.
At Nevada Medicare we can guide and help you through these processes – call us for a hassle-free help. Contact Us today.