What Drugs Are Covered By Medicare Part D

First Of All What Is Medicare Part D

All across the nation, many Medicare beneficiaries rely on prescription medications to maintain their quality of life. This includes those over the age of 65 and those who have been diagnosed with certain diseases or disabilities.

Medicare Part D is primarily focused on Medicare drug coverage, and is responsible for helping you pay for the costs associated with prescription medications. Like Medicare Advantage, Medicare Part D plans are offered by private insurance providers.

As a result, the exact pricing, benefits, and drugs you are eligible to receive coverage for can vary from plan to plan , but most common outpatient drugs can be covered by Medicare Part D. Medicare Part D coverage can usually be bundled into a Medicare Part C plan, but Part D can also be had as a standalone plan as well.

Are There Special Rules I Need To Consider

Some prescription drugs require that you adhere to special rules before your insurer will cover them. For example:

• Step therapy: If this is the first time youre taking a drug, you may be required to start with a more cost-efficient version before you can move onto a more expensive medication.
• Prior authorization: Your doctor will need to get approval before the plan will pay for a drug.
• Quantity limits: Certain drugs, such as opioids, will have limits on the number of doses and/or refills that your insurer will cover.

Your plan’s drug list will tell you which drugs require step therapy, prior authorization and quantity limits. If your medication falls into any of these categories, you may need to take action before the plan will cover the drug. Check with your doctor about your options.

Cigna Medicare Advantage Plans

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Medicare Prescription Drug Plans

Get help covering the cost of your prescription drugs. A stand-alone Medicare prescription drug plan can help pay for your medication. You can also get prescription drug coverage as part of a Medicare Advantage plan.

You must live in the service area of the Part D plan to enroll, and some plans will have a network of pharmacies they work with. With prescription drug coverage, in addition to costs varying by plan and provider, your costs may be different based on if a pharmacy is considered in-network or out-of-network, as well as if your drugs are separated into different cost levels, or tiers.

Note for Veterans: People who have benefits through the Veterans Affairs may be able to get prescription drug coverage through the VA and may not need Medicare drug coverage. Talk with your VA benefits administrator before making any decisions.

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 or weight gain drugs
• Drugs for cosmetic purposes or hair growth
• Fertility drugs
• Drugs for sexual or erectile dysfunction
• Over-the-counter drugs

Medicare Part D also does not cover any drugs that are covered under Medicare Part A or Part B.

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What Should I Know About A Plan’s Drug List

Medicare Part D and Medicare Advantage plans have a drug list that tells you what drugs are covered by a plan. Medicare sets standards for the types of drugs Part D plans must cover, but each plan chooses the specific brand name and generic drugs to include on its formulary. Here are some important things to know:

• A plan’s drug list can change from year to year.
• Plans can choose to add or remove drugs from their drug list each year. The list can also change for other reasons. For example, if a drug is taken off the market. Your plan will let you know if there’s a coverage change to a drug you’re taking.
• Many Part D plans have a tiered formulary.

Understanding The Donut Hole Coverage Gap

For most Medicare prescription plans, there is a temporary limit on what the plan covers. This is called the coverage gap, or the donut hole. In 2022, this coverage gap will be triggered once you and your plan spend a combined $4,430 on covered medications. Once youre in the coverage gap, you will pay a maximum of 25% of the cost for brand-name drugs in your plan. Although you pay only a fraction of the cost of your prescriptions, almost the full price of the drugs count toward your out-of-pocket costs.

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Medicare Part D Senior Savings Model

Insulin costs always seem to rise, which is a significant problem for many Medicare beneficiaries. These high prescription costs affect more than 3 million seniors. For many going without this necessary medication isnt an option. Failure to use it correctly can cause serious health concerns.

In January 2021, the Trump administration set forth an initiative called the Part D Senior Savings Model. The program was introduced to create lower costs and increase the affordability of insulin.

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Types Of Medicare Advantage Plans

Within Medicare Advantage, there are several plan types13. Each plan follows different rules, which may vary depending on the insurance provider.

Health Maintenance Organizations

HMOs14 only allow beneficiaries to obtain care within a specific network of physicians. If an enrollee requires specialist care from a physician outside the network, their primary care physician must provide a written referral. Any out-of-network care that hasn’t been referred is not typically covered by the plan.

Private Fee-for-Service Plans

PFFS15 plans are flexible, allowing members to obtain care from the physician or health care practitioner of their choice. These plans provide enrollees with a set fee for each health care service, and any expense beyond that dollar amount is the responsibility of the enrollee.

Preferred Provider Organizations

PPOs16 operate in a similar way to HMOs, having a specific network that members are recommended to seek care from. However, in a PPO, members may seek care outside of their network. While these plans give members the freedom to see any doctor they choose, receiving care from a practitioner outside of their PPO network usually costs more.

Special Needs Plans

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How To Find A Plan

There is no single Medicare drug plan. To get coverage, you must enroll in a Medicare-approved private drug plan. There are at least two ways to get Medicare prescription drug coverage. You can join a Medicare prescription drug plan or you can join a Medicare Advantage plan with prescription drug coverage.

• Visit the Medicare Prescription Drug Plan Finder to find a Medicare prescription drug plan in your area. You may either search for plans by entering your Medicare claim number and other personal information or by entering only your ZIP code. Providing your personal information will ensure you receive the most accurate results for the new Medicare drug benefit, how it applies to you, and how much you will pay.
• Contact your local Area Agency on Aging at 800-252-9240 for assistance understanding Medicare prescription drug coverage.

Does Medicare Cover Prescription Drugs

En español No, Medicare doesnt automatically cover prescription drugs you get at a pharmacy, but you can buy a Medicare Part D plan from a private insurer to help cover those expenses. You can either get a stand-alone Part D plan or purchase a Medicare Advantage plan that provides medical and drug coverage in its benefits package.

Medicare introduced these prescription drug coverage benefits in 2006. In 2021, 77 percent of all Medicare beneficiaries 48 million people were enrolled in Part D plans. Half had stand-alone Part D plans, and half were in Medicare Advantage drug plans, according to the Kaiser Family Foundation.

Specific coverage varies by plan, and you usually have many to choose from, depending on your location. In 2022 the average Medicare beneficiary had a choice of 23 stand-alone Part D plans and 31 Medicare Advantage plans. Find out about the plans available in your area by typing your zip code into Medicares Plan Finder.

Other parts of Medicare generally cover drugs that medical professionals provide at a doctors office, hospital or specialty clinic. For example, Medicare Part B covers chemotherapy, dialysis and other medications injected or given intravenously at a doctors office or outpatient center.

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Medicare Coverage Of Preventive Mental Health Services

Medicare Part B covers preventive services that address your mental health, including screenings to identify your risk for depression or substance abuse. You generally need to get these services from a Medicare-assigned health provider in a Medicare-enrolled facility to make sure Part B covers them.

Preventive benefits related to mental health coverage include:

• Depression screening: All Medicare Part B beneficiaries are covered for one depression screening every year at no cost, so long as the doctor accepts Medicare assignment.
• Alcohol misuse screening: All Medicare Part B beneficiaries who arent alcohol-dependent are covered for one alcohol misuse screening every year. If your doctor determines you misuse alcohol, you may qualify for up to four counseling sessions per year.
• Welcome to Medicare visit: This one-time preventive exam includes a review of your overall health and includes an evaluation of your risk for depression. The visit is completely covered if you have the visit within the first year of having Medicare Part B.
• Wellness visit: After the introductory visit, all Medicare Part B enrollees are covered for one preventive visit every year. If you have any questions or concerns about your mental well-being, youll have the chance to speak with your doctor during this exam. Your doctor may discuss treatment options or refer you for additional care.

Joining A Medicare Drug Plan May Affect Your Medicare Advantage Plan

If you join a Medicare Advantage Plan, youll usually get drug coverage through that plan. In certain types of plans that cant offer drug coverage or choose not to offer drug coverage , you can join a separate Medicare drug plan. If youre in a Health Maintenance Organization, HMO Point-of-Service plan, or Preferred Provider Organization, and you join a separate drug plan, youll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare.

You can only join a separate Medicare drug plan without losing your current health coverage when youre in a:

• Private Fee-for-Service Plan
• Certain employer-sponsored Medicare health plans

Talk to your current plan if you have questions about what will happen to your current health coverage.

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How Much Will My Prescription Drugs Cost

Several factors determine how much you will pay for your prescriptions.

• The plan you choose. Each plan sets its own cost-sharing by tier. Check with your plan about incentives, such as discounted pricing on 90- or 100-day supplies.
• Whether your pharmacy is inside your plans network. Generally, you need to use a pharmacy in your plans network for the medication to be covered. Some plans have preferred pharmacies where you could save even more.
• Whether the drug you take is on the covered drug list . Generally, plans will only cover medications if the drug is on their covered drug list . Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money.
• What tier your medication is on. Plans place their drugs on different tiers which determine costs. Generally, the lower the tier, the less you pay.
• Whether your plan has a deductible. With a deductible, you pay for the full cost of your medication until youve met the deductible amount.
• Whether you qualify for extra subsidies. There are programs available to help people with limited incomes pay prescription drug costs. Learn how you may be able to qualify to get help.

Changes In A Part D Formulary

Each Medicare Prescription Drug Plan is required to publish its formulary on the planâs website. The plan must also tell you when it removes drugs from the Part D formulary. The formulary may change at any time. You will receive notice from your plan when necessary.

Medicare Prescription Drug Plans are restricted from making changes to the listed drugs â or changing the tiered pricing â between the beginning of the planâs annual election period until 60 days after the plan coverage begins. The exception to this is if the FDA determines a drug is unsafe or a manufacturer removes a drug from the market.

Mid-year changes to formulary drugs are limited, and your plan must always notify you of such changes. The notification of change must include the name of the drugs, Part D change type , the reason for the change, alternate drugs, new Part D cost sharing, and exceptions.

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Medicare Part D Prescription Drug Coverage And Mental Health Care

Medicare Part D prescription drug plans are not required to cover all drugs, but with limited exceptions, they are required to cover all antidepressant, anticonvulsant and antipsychotic medicines.

Part D plans are sold by private insurers and other companies that Medicare approves. Almost all plans have a formulary a list of drugs the plan covers. This list can change each year, but the company has to notify you at least 30 days before the change takes effect.

Its important to review your plans formulary changes when you receive this information.

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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.

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Your Medicare Part D Rights

If you have a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, you have the right to:

• Receive âcoverage determinationâ â 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 planâs prior authorization, and requirements for making coverage exceptions.
• Ask for exceptions to drugs not covered by your planâs formulary.
• Ask for exceptions to waive plan coverage rules .
• Ask for a lower copayment for higher-cost drugs if you or your prescriber believe you cannot take any of the lower-cost drugs for the same condition.

Do you have more questions? Connect with any of our licensed insurance agents to answer your Medicare questions or discuss a Medicare plan option that may be right for you.

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What Drugs Must Part D Cover

Each Medicare Part D plan has a formulary, a list of covered medications, that includes both generic and brand-name prescriptions. You generally will have higher out-of-pocket costs for brand-name drugs.

Formularies vary from plan to plan, but federal law requires that all Medicare Part D plans include at least two drugs in the most commonly prescribed categories and all medications in the following categories:

• Anticancer drugs except where covered by Part B
• Anticonvulsive treatments for seizure disorders
• Antidepressants
• Immunosuppressant drugs

Part D plans must include coverage for most commercially available vaccines, including inoculations to prevent shingles. Part B, though, covers flu, hepatitis B and pneumonia vaccinations. The government also will pay for your COVID-19 vaccinations if you are covered under any of the four parts of Medicare.

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