How To Get Prescription Drug Coverage
Medicare drug coverage helps pay for prescription drugs you need. Even if you dont take prescription drugs now, you should consider getting Medicare drug coverage. Medicare drug coverage is optional and is offered to everyone with Medicare. If you decide not to get it when youre first eligible, and you dont have other creditable prescription drug coverage or get Extra Help, youll likely pay a late enrollment penalty if you join a plan later. Generally, youll pay this penalty for as long as you have Medicare drug coverage. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage. Each plan can vary in cost and specific drugs covered.
What Part D Covers
Medicare Part D plans offer you a way to control the cost of prescription medications. Before Part D was introduced in 2006, Medicare recipients generally paid the entire cost of their medications or bought Medicare Supplements that, at the time, had a very limited amount of drug coverage. What Part D covers now provides us with a much better solution.
What Can Cause A Vitamin D Deficiency
Vitamin deficiency can occur for a number of reasons. Risk factors that can affect the bodys ability to produce or absorb adequate vitamin D include:
- Advanced age
- Lack of sun exposure
- Medical conditions that limit fat absorption, including liver disease, ulcerative colitis and cystic fibrosis
Certain medications, such as steroids, anti-seizure drugs and stimulant laxatives may also prevent your body from effectively absorbing and processing vitamin D.
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Introduction To Medicare Part D
This section constitutes an introduction to Part D. For more detailed information on any of the topics in this section, please click on the links within the topics. There, you will also find relevant legislative, statutory and CFR citation.
Prior to 2006, Medicare paid for some drugs administered during a hospital admission , or a doctors office . Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit, authorized by Congress under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This Act is generally known as the MMA.
The Part D drug benefit helps Medicare beneficiaries to pay for outpatient prescription drugs purchased at retail, mail order, home infusion, and long-term care pharmacies.
Unlike Parts A and B, which are administered by Medicare itself, Part D is privatized. That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy offered by one of these companies.
The costs associated with Medicare Part D include a monthly premium, an annual deductible , co-payments and co-insurance for specific drugs, a gap in coverage called the Donut Hole, and catastrophic coverage once a threshold amount has been met.
What Types Of Vitamins And Supplements May Be Covered By Medicare
Medicare Part B might provide coverage for the following vitamins and supplements in certain situations:
- Prenatal vitamins
- Vitamin D analogs . Doctors sometimes prescribe these to treat or prevent certain conditions for example, calcitriol may be used for bone disease or low calcium levels, according to the National Institutes of Health.
- Fluoride preparations
- Certain prescription drugs to treat weakness or loss of muscle mass due to HIV/AIDS
- Sodium, calcium, potassium, and magnesium when used to boost your electrolytes
Medicare may provide coverage for vitamins or vitamin supplements when your doctor prescribes them as part of a recognized and accepted treatment for a disease you have. The list above may not include every vitamin supplement covered by Medicare.
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Does Medicare Cover Vitamins
Medicare Part B or Part D vitamin coverage is generally only present in the context of a medical diagnosis and recommendation by a physician, but some Medicare Advantage or Prescription Drug Plans may cover additional vitamin supplements.
Let’s take a look at some instances where Medicare might cover vitamin supplementation:
- Vitamin D and calcium are backed by evidence as being useful for conditions such as low bone density. A doctor may prescribe them for certain conditions, such as low calcium levels and bone disease.
- Niacin is approved for prescription by the FDA for dyslipidemia and isn’t universally excluded from Medicare coverage.
- Part B Medicare coverage includes specific vitamins and supplements for pregnant women if they’re recommended by a physician.
- Fluoride preparations when prescribed by a medical professional.
- Growth hormone and megestrol acetate for the treatment of certain AIDS-related conditions.
- Medicare Part A covers mineral supplementation for potentially life threatening electrolyte imbalances.
What Medicare Part D Covers
Medicare Part D allows for coverage of most retail prescription drugs in the United States. Each plan maintains a list of medications, or formulary, that it covers. Medicare requires that the plan must offer at least two 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.
There are a few types of medications that Medicare does not require drug plan carriers to include in their formularies. These are:
- Barbiturates sedatives or other drugs that depress the central nervous system
- Benzodiazepines commonly prescribed for insomnia or anxiety
- Fertility or erectile dysfunction medications
- Drugs for cosmetic reasons, such as hair growth
- Drugs for weight loss, weight gain, or anorexia
- Prescription strength vitamins and minerals
- Cough syrups or other meds that treat cold symptoms
- 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.
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Medicare Part D Formulary Tiers
Medicare uses a tier system to organize prescription medications by price. The amount that someone pays for medication depends on the tier.
Drugs in lower tiers usually cost less than those in higher tiers. Most plans have a four-, five-, or six-tier system:
- Tier 1: Unbranded drugs with the lowest cost.
- Tier 2: Other generic drugs, but with a higher cost than tier 1.
- Tier 3: Branded drugs of preferred brand.
- Tier 4: Nonpreferred drugs with a higher cost than tier 3.
- Tier 5: Specialty drugs with the highest cost.
- Tier 6: Select care drugs that may have a lower copayment than tier 1 drugs.
The various Part D plans may classify the same medication in different tiers. Copayments and coinsurance may vary based on the tier level.
D Appeals And Grievances
Coverage Determinations and Exceptions
All Part D plans must have an appeal process through which members can challenge a denial of drug coverage. The Part D appeals process is based on and similar to the Part C appeals process.
Denials of drug coverage by a PDP or MA-PD are called coverage determinations. For example, a coverage determination may be issued by the plan if the drug is not considered medically necessary or if the drug was obtained from a non-network pharmacy. It is necessary to have a coverage determination in order to initiate an appeal. A doctors supporting statement is not required for this type of appeal, but it may be helpful to submit one. If the request for coverage is denied, the member may proceed to further levels of appeal, including redetermination by the plan, reconsideration by an Independent Review Entity , Administrative Law Judge review, the Medicare Appeals Council , or federal district court.
One type of coverage determination is called an exception request. An exception request is a coverage determination that requires a medical statement of support in order to proceed to appeal. There are two types of exceptions that may be requested:
Formulary Exceptions This type of exception is requested because the member:
- needs a drug that is not on the plans formulary,
- requests to have a utilization management requirement waived for a formulary drug).
What to do When a Drug is Denied at the Pharmacy
The Medical Statement
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What Drugs Are Excluded From Part D Plans
The drugs that are excluded from Part D by Medicare are: Drugs used for anorexia, weight loss, or weight gain Drugs used to promote fertility Drugs used for cosmetic purposes or hair growth Drugs used for the symptomatic relief of cough and colds Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations Non-prescription drugs Inpatient drugs Barbiturates – except when used to treat epilepsy, cancer, or a chronic mental health disorder In addition, a drug cannot be covered under a Part D plan if payment for that drug is available under Part A or B of Medicare, such as drugs administered in a hospital or a physician’s office. Also, each Part D prescription drug plan may have its own specific exclusions.
Can I Change Part D Plans Once I Have Enrolled
Yes, you can change your Part D plan. The opportunities to switch are: Annual enrollment: Each year, you will be able to choose a different Part D prescription drug plan or Medicare Advantage plan during an annual enrollment period that lasts from October 15 through December 7. Coverage under the new plan will begin the following January 1. Other exceptions: There are other limited exceptions that may give you the right to switch plans during a year. For example, if you move out of the service area of your current plan, you will have an opportunity to choose another plan that serves your new area
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Consider All Your Drug Coverage Choices
Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs , the Indian Health Service, or a Medicare Supplement Insurance policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options.
If you have other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you make any changes to your current coverage.
Where In The Law Does It Say They Aren’t Covered
Coverage requirements for Medicare Part D drugs are defined in the Title XVIII of the Social Security Act. Also listed in the Social Security Act ) are drugs that are excluded from coverage.
Drugs that are excluded from coverage are:
- Those used for anorexia, weight loss, or weight gain.
- Those used to promote fertility.
- Those used for cosmetic purposes or hair growth.
- Those used for the symptomatic relief of cough and colds.
- Those used to promote smoking cessation.
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
- Non-prescription drugs
- Those used for the treatment of sexual or erectile dysfunction .
There are some exceptions to the above list.
Part D law states that benzodiazepines and barbiturates are now covered when being used for FDA-approved indications. Smoking cessation products are covered as well.
Unfortunately, drugs for erectile dysfunction are still not covered. These include:
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Does Medicare Cover Vitamin D Testing
- Vitamin D is essential to good health, and many doctors include a screening with routine blood work. Explore Medicare coverage criteria for vitamin D testing.
Adequate vitamin D is essential to good health, supporting lung function, immune health and strong bones, and many doctors now include a vitamin D screening with other routine blood work. Because maintaining healthy levels of this nutrient is even more important as you age, Medicare covers vitamin D testing for beneficiaries who may be at risk for a deficiency. In this article, you’ll find an overview of vitamin D and what it does, as well as coverage criteria for vitamin D testing under Original Medicare and Medicare Advantage.
Your Medicare Part D Plan Doesnt Cover A Drug Now What
Drugs that aren’t covered by your Part D Plan can bust your healthcare budget.
Here is a dilemma many Medicare beneficiaries face:
My physician ordered a new medication to treat a longstanding medical problem. The pharmacist said my drug plan doesnt cover this drug. I really need to take it. What can I do?
This is not a rare event. Yet, many beneficiaries are surprised to discover that an essential drug is not covered by their Part D plan. They believe the plan should cover their medications, so whats the problem? Understanding what drug plans can and cannot cover is a good place to start.
Drugs that a plan cannot cover
- Drugs to treat anorexia, weight loss or weight gain, cold or cough symptoms, erectile dysfunction, or fertility problems
- Drugs for cosmetic purposes or hair growth
- Prescription vitamins and minerals, and
- Over-the-counter drugs .
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Eligibility For Part D
Anyone with Medicare is eligible to enroll in a Part D plan. To enroll in a PDP, the individual must have Part A OR Part B. To enroll in an MA-PD, the individual must have Part A AND Part B.
Enrollees must live in their plans service area. In the case of homeless persons, the following may be used as a permanent residence: a Post Office box, the address of a shelter or clinic, or the address where the person receives mail such as Social Security checks.
PDPs are usually national plans, but MA-PDs have delineated regions, sometimes by state, sometimes by counties within states ). For this reason, MA-PDs may not be appropriate for those who travel a great deal or who maintain summer and winter residences in different areas of the country. NOTE: Some MA-PDs offer passport plans that allow members to obtain benefits outside their normal service areas.
Individuals who reside outside the United States* are not eligible to enroll, but may do so upon their return to the country. Incarcerated individuals may not enroll in Part D, but they may enroll upon release from prison. Prior to 2021, people with end-stage-renal-disease could not enroll in an MA-PD. Starting in 2021, people with ESRD can enroll in Medicare Advantage plans during the annual Open Enrollment Period.
There are no other eligibility restrictions or requirements for Part D.
What About Other Vitamins And Supplements
Some Medicare Prescription Drug Plans might cover certain vitamins and supplements. Every Medicare Prescription Drug Plan has its own formulary, or list of covered drugs. Generally, Medicare Part D doesnât cover vitamin supplements, as mentioned above.
But Medicare Prescription Drug Plans that have âenhanced alternative coverageâ included in their benefits might cover some vitamins and supplements. Enhanced alternative coverage means the planâs formulary contains additional items that exceeds standard Medicare Part D coverage.
You may want to contact your plan to find out if it offers enhanced alternative coverage and what, if any, prescription vitamins and supplements are covered.
A planâs formulary may change at any time. You will receive notice from your plan when necessary.
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Medicare And Nutritional Therapy
If you have Kidney disease, Diabetes, or you have had a kidney transplant in the past 36 months, your doctor may prescribe Nutritional Therapy.
Medicare Nutritional Therapy and related services include:
- Current nutrition and lifestyle assessment
- Nutrition counseling,
- Management of nutrition and lifestyle factors that affect your kidney or cause Diabetes
- Group nutrition therapy, and follow up visits.
Your doctor may prescribe some vitamins and supplements to help with the conditions. You may not have to pay for the Nutritional Therapy services or vitamins and supplements prescribed by your doctor if you have Medicare part B or Medicare Advantage.
Every Medicare Part D Prescription plan has a list of drugs that it covers. They might cover some vitamins and supplements. Medicare Advantage plans may cover some vitamins and supplements. Since private companies sell Medicare Advantage plans, they may offer additional benefits that allow enrollees to buy non-prescription vitamins or supplements over the counter within a monthly limit. However, it is not a requirement.
What Are The Symptoms Of Vitamin D Deficiency
Without a blood test, vitamin D deficiency may go undetected. However, the following symptoms may indicate low levels of this vitamin:
- Slow-to-heal wounds
- Frequent bouts of sickness or infection
If youre exhibiting one or more of these symptoms, your doctor may recommend a screening for vitamin D levels.
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What Does Medicare Part D Cost
Like Medicare Advantage plans, Part D stand-alone plans will also vary in costs based on the plan you choose. Each plan negotiates prices with drug manufactures and pharmacies. Your copays and coinsurance rates are based on these prices and on guidelines set by Medicare. You can find explanations of specific drug costs in each Part D plan’s Summary of Benefits or Evidence of Coverage materials.
Your total prescription drug costs will also be impacted by the number of prescriptions you take, how often you take them, if you get them from an in-network or out-of-network pharmacy, and what Part D coverage stage you are in. Your costs may also be less if you qualify for the Extra Help program.
First, let’s look at what kinds of costs you could pay for Part D, then dive into the different coverage stages and how they work.