Friday, July 12, 2024

What Medications Are Covered By Medicare

Don't Miss

D Plan Premiums And Benefits In 2022

Medications Not Covered by Medicare


The 2022 Part D base beneficiary premium â which is based on bids submitted by both PDPs and MA-PDs and is not weighted by enrollment â is $33.37, a modest increase from 2021. But actual premiums paid by Part D enrollees vary considerably. For 2022, PDP monthly premiums range from a low of $5.50 for a PDP in Colorado to a high of $207.20 for a PDP in South Carolina . Even within a state, PDP premiums can vary for example, in Florida, monthly premiums range from $7.70 to $174.30. In addition to the monthly premium, Part D enrollees with higher incomes pay an income-related premium surcharge, ranging from $12.30 to $77.10 per month in 2021 .


The Part D defined standard benefit has several phases, including a deductible, an initial coverage phase, a coverage gap phase, and catastrophic coverage, although it does not have a hard cap on out-of-pocket spending. Between 2021 and 2022, the parameters of the standard benefit are rising, which means Part D enrollees will face higher out-of-pocket costs for the deductible and in the initial coverage phase, as they have in prior years, and will have to pay more out-of-pocket before qualifying for catastrophic coverage .

  • The standard deductible is increasing from $445 in 2021 to $480 in 2022
  • The initial coverage limit is increasing from $4,130 to $4,430, and
  • The out-of-pocket spending threshold is increasing from $6,550 to $7,050 .

Figure 6: Medicare Part D Standard Benefit Parameters Will Increase in 2022â

Paying For Your Prescription Drugs

If you prefer to remain with the same Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan and your request for a formulary exception was denied, you may have to pay full price for your prescription drug, instead of the usual copayment or coinsurance. Choosing a generic medication instead of a brand-name prescription drug may be your best option if your doctor decides that could work for your health condition.

Some prescription drug manufacturers offer payment assistance programs, especially for newer or expensive medications. You would need to contact the prescription drug manufacturer on your own to explore this possibility.

Do you have questions about your options if your Medicare plan doesnt cover a medication you need? If youd like assistance finding Medicare Part D coverage that may cover your prescription drugs, feel free to contact eHealth to speak with a licensed insurance agent. Were here to help.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

New To Medicare?

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.

Also Check: Can I Get Glasses With Medicare

Special Drug Coverage Rules

Some drugs have special coverage rules that may:

  • Limit the amount of a particular drug you can get
  • Require that you get prior approval from the plan before a drug is covered
  • Require that you first try a certain drug to treat your condition before another drug is covered
  • Limit which pharmacies you can use

Drugs that are subject to these rules are clearly marked in the formulary.

View the list of prescription drugs that currently have prior authorization or step therapy requirements and the rules that apply to each drug:

Saver plan

View General Prescription Drug Lists

What Drugs Does Medicare Part D Cover

View the lists below to find general pharmacy benefits information for UnitedHealthcare plans, including certain PDLs. Remember, this is only general information. Sign in on or call the number on your health plan ID card to see your PDL and get specific information about your pharmacy benefits.

Also Check: When Can You Get Medicare Health Insurance

How Do I Get Prescription Drug Coverage

To get coverage for most prescriptions you may take routinely, you need to get Medicare prescription drug coverage. You can get prescription drug coverage through most Medicare Advantage Prescription Drug Plans or a stand-alone Medicare Prescription Drug Plan .

While Medicare Part D coverage is an optional benefit, if you dont sign up when youre first eligible you may have to pay a penalty to get covered later on.

Ask Your Doctor About Substitutes

If the non-covered prescription drug is a brand-name medication, ask your doctor if there are any generic equivalents that would work as well as the non-covered medication. You can also ask your doctor if there are any other prescription drugs your Medicare plan does cover that would be effective for treating your health condition.

You May Like: When Do You Receive Medicare Card

What Medicare Drug Plans Cost

Medicare drug coverage carries premiums beyond what you pay for original Medicare.

Part D premiums vary by plan. In 2020 the average base monthly premium is $32.74 a month, according to the Centers for Medicare & Medicaid Services.

The base rate is what most enrollees pay for their Part D plan. But if you earn more than a certain amount, you are subject to a rate adjustment that Medicare sets.

In 2020, this adjustment starts at $12.20 a month above your regular Plan D premium if the gross income reported on your tax return is more than $87,000 for a single filer or $174,000 for a married couple filing jointly. It rises in steps to $76.40 a month above the base rate for incomes of more than $500,000 for singles or $750,000 for couples.

Copayments or coinsurance will have to be paid on most prescriptions, in addition to premiums. Your plan also may carry an annual deductible.

Youll pay in full for prescriptions until you hit that deductible, after which Medicare starts paying its share. Deductibles vary among plans but by law cannot exceed $435 in 2020.

Medicares Extra Help program offers financial assistance to people with low incomes or limited resources to meet their Medicare prescription drug costs.

Editor’s note: This article was originally published on July 15, 2015. It has been updated with the latest information regarding Medicare coverage in 2020.

Receiving Benefits From Ontario Works Or Ontario Disability Support Program

Part D Prescription Drug Coverage through Medicare Advantage Plans

If you receive benefits from one of these programs, you are automatically covered by the Ontario Drug Benefit. You pay up to $2 for each drug filled or refilled and you do not have to pay a deductible.

If you are aged 24 and under and have no private insurance or are receiving benefits from one of these programs, you do not have to pay the $2 for each drug filled or refilled.

Ask your Ontario Works or Ontario Disability Support Program case worker how it works. Your pharmacist can also tell you.

Recommended Reading: What Is The Extra Help Program For Medicare

Understanding Medicare Part D Prescription Drug Coverage

An animated white speech bubble appears over an animated character’s green and white head.

ON SCREEN TEXT: What is a Medicare Part D Plan?

The character and speech bubble separate and exit the screen on opposite sides. Blue text appears above a sheet of paper.

ON SCREEN TEXT: Medicare Part D plans are…

The paper and text slide up. Blue text appears, along with blue and white pill bottles.

ON SCREEN TEXT: Stand-alone plans that provide prescription drug coverage.

A bottle covers the text and turns over as pills pour out of it.

ON SCREEN TEXT: Part D plans cover certain common types of drugs as regulated by the federal government, but each plan may choose which specific drugs it covers.

The text disappears as the camera moves down to show another sheet of paper.

ON SCREEN TEXT: The list of drugs a plan covers is called a formulary.

Text appears on the paper.

ON SCREEN TEXT: Part D plans do not cover:

ON SCREEN TEXT: Drugs that aren’t on the plan’s formulary

ON SCREEN TEXT: Drugs that are covered under Medicare Part A or Part B

The text is crossed out with a blue line as the page scrolls down.

ON SCREEN TEXT: Drugs that are excluded by Medicare

More text is crossed out with a blue line. After the page scrolls down, the last chunk of text is crossed out with a blue line. The screen swipes down and white text appears on a blue background.

ON SCREEN TEXT: Medicare Made Clear® by UnitedHealthcare

What Are Medicare Part B Covered Drugs

Medicare Part B covered drugs include a limited number of prescription drugs such as those you get in a hospital outpatient department under certain circumstances, injected drugs you get in a doctor’s office, certain oral cancer drugs, and drugs used with some types of durable medical equipment .

Medicare Part B drugs include, but are not limited to, the following types of drugs:

  • Durable Medical Equipment Supply Drugs such as: nebulizers, external or implantable pumps
  • Hemophilia clotting factors: Self-administered clotting factors if you have hemophilia
  • Immunosuppressive Drugs: Immunosuppressive drug therapy a beneficiary has received from a Medicare-covered organ transplant
  • Oral Anti-Cancer and Anti-Nausea Drugs
  • Pneumococcal and Hepatitis B vaccines and administration

For additional information on Medicare Part B covered drugs, refer to your Summary of Benefits or Evidence of Coverage .

Part B Drugs may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Please contact the plan for additional information.

You May Like: When Can Medicare Plans Be Changed

Whos Eligible For Medicare Prescription Drug Coverage

You are eligible for Medicare drug coverage under Part D or under a Medicare Advantage plan if youre enrolled in either Medicare Part A or B.

You become eligible for Medicare starting 3 months before your 65th birthday and extending to 3 months after your birth month.

Even though enrollment in Part D is optional, you must have some form of prescription drug coverage. This will help you avoid paying a penalty for late enrollment when you become eligible.

You can also check to see if youre eligible for Medicares Extra Help program to pay for premiums, deductibles, and copays.

Once you turn 65 years old and are eligible for Medicare, you can enroll in Part A and B. During the Part D enrollment period, you can then choose a Part D plan to help with prescription drug coverage.

Choose a plan based on:

  • coverage of the medications you take
  • out-of-pocket expenses
  • premiums
  • selection of pharmacies available

Remember, you have to enroll in a plan every year. So, if a plan didnt meet your needs or expectations, you can switch to another plan. Youre not locked into a plan forever.

You can use Medicares plan finder tool to search for:

  • Medicare Part D plans
  • Part D plans with Medigap
  • Medigap plans available where you live

Youll need to provide proof that youre enrolled in original Medicare, like your Medicare number, and the date your coverage started.

There Are 2 Ways To Get Medicare Drug Coverage:

Medicare Part D: Coverage, exclusions, costs, and eligibility

1. Medicare drug plans. These plans add drug coverage to Original Medicare, some Medicare Cost Plans, some Private FeeforService plans, and Medical Savings Account plans. You must have


to join a separate Medicare drug plan.

or other

with drug coverage. You get all of your Part A, Part B, and drug coverage, through these plans. Remember, you must have Part A and Part B to join a Medicare Advantage Plan, and not all of these plans offer drug coverage.

To join a Medicare drug plan, Medicare Advantage Plan, or other Medicare health plan with drug coverage, you must be a United States citizen or lawfully present in the United States.

Visit to get specific Medicare drug plan and Medicare Advantage Plan costs, and call the plans youre interested in to get more details. For help comparing plan costs, contact your State Health Insurance Assistance Program .

Don’t Miss: Should I Get Medicare Supplemental Insurance

What Part D Covers

All Part D drug plans must provide a minimum coverage level set by Medicare. However, the type of drugs covered depends on the formulary. A formulary is a list of prescription drugs covered by the Part D plan. Formularies vary from plan to plan.

Formularies are broken into tiers. Each tier has a different cost-sharing amount. For example, Tier I drugs may include low-cost generic medications while Tier III drugs may include non-preferred name-brand medications.

If youre enrolled in Original Medicare, you must purchase Part D coverage separately. Most Medicare Advantage plans include Part D coverage.

What Youll Pay for Part D

  • Medicare Part D costs vary depending on your medications, the plan you select and the pharmacy you use.

Medicare Coverage Of Bone Mass Density Tests

Medicare covers a bone mass screening test, or bone density test, once every 24 months or more often if medically necessary when you meet certain criteria.

Bone density tests establish a formal diagnosis of osteoporosis. They can also assess the efficiency of osteoporosis drug therapy by identifying your bone mass and quality.

Qualifying Medicare beneficiaries pay nothing for bone mass tests.

To qualify for Medicare coverage of a bone mass test, you must meet one of the following conditions:

  • Youre a woman whose doctor determines youre at risk for osteoporosis.
  • Your X-rays show possible osteoporosis.
  • Youre taking prednisone or steroid-type drugs, or plan to begin these treatments soon.
  • Youve been diagnosed with primary hyperparathyroidism.
  • Youre being monitored to see if your osteoporosis drug therapy is working.

There are several different procedures your doctor may use to test your bone density.

Types of Bone Density Tests Covered by Medicare

  • Dual energy X-ray absorptiometry
  • Radiographic absorptiometry
  • Single energy X-ray absorptiometry
  • Quantitative computed tomography

While these preventative services are free for Medicare beneficiaries who qualify, research shows that bone mass tests are often underutilized.

According to a 2019 report commissioned by the National Osteoporosis Foundation, 2 million Medicare recipients suffered fractures in 2015.

Recommended Reading: When Can You Apply For Part B Medicare

What Is Erectile Dysfunction

Mayo Clinic defines erectile dysfunction, also known as impotence, as the inability to get and keep an erection firm enough for sex.

Symptoms of ED include trouble getting an erection, trouble keeping an erection and reduced sexual desire.

Underlying health conditions often contribute to erectile dysfunction. Other times, medications and other treatments may be necessary.

Some medications make it more difficult to keep or maintain an erection.

Common medications that may include ED as a potential side effect include:

  • High blood pressure drugs
  • Antihistamines

Will Medicare Part D Pay For All Of My Prescriptions

What is Covered by a Medicare Drug plan?

Not necessarily.

You might take a medication that your Medicare Part D Plan does not cover unless you prove it is medically necessary. You may need to work with your doctor to prove you need that medication or to find a suitable alternative medication, or you may need to change to a Medicare Part D Plan that covers the medication.

You might take a medication that is not covered by Medicare Part D at all, or is not covered for your diagnosis. That means no Medicare Part D Plan will cover it, even if you prove it is medically necessary.

Among the medications not covered by Medicare Part D at all are the “excluded” drugs, including:

NOTE: If you are a member of MaineCare, the Medicare Savings Program, or the Drugs for the Elderly program , those programs may pay for some of the drugs listed above. Be sure your pharmacist knows you are in MaineCare, the Medicare Savings program and/or DEL.

In addition, some medications are covered by Medicare Part B, and not covered by Medicare Part D or only covered by Medicare Part D in some situations. In those cases, your pharmacist should bill Medicare Part B.

To find out which Medicare Part D plan’s formulary will best meet your prescription needs, go to the Medicare website Formulary Finder,

Call your local Area Agency on Aging at or TTY: .

NOTE: If you cannot find a plan that covers all of your drugs, you may be able to enroll in a plan and request an “Exception” to obtain full coverage.

You May Like: Does Medicare Cover Bladder Control Pads

Drugs Used To Treat Hiv/aids

Many drugs used to treat HIV/AIDS are covered by the Ontario Drug Benefit program for eligible Ontarians when prescribed by a doctor who is registered on the ministrys Facilitated Access HIV/AIDS Physician list. If you do not have a doctor who is registered on this list, you will need to be referred to one.

How To Join A Drug Plan

Once you choose a Medicare drug plan, here’s how to get prescription drug coverage:

When you join a Medicare drug plan, you’ll give your Medicare Number and the date your Part A and/or Part B coverage started. This information is on your Medicare card.

Also Check: What Does Part B Cover Under Medicare

Adverse Reactions To Generic Drugs

If youve had bad reactions to at least two generics, the ODB program covers the brand-name drug. In this case, your doctor:

Once filled out by your doctor, take the form and prescription to your pharmacist. Your pharmacist submits the completed form to Health Canada, which monitors drug safety.

More articles

Popular Articles