Not long ago, my brother-in-law told his doctor that one of his medicines didn’t seem to be working as well as it had in the past. The doctor prescribed something new. The old medication cost about $20. The new prescription was $232. My brother-in-law had to pay the entire amount of the new medicine.
My brother-in-law’s situation is not an isolated case. There is a widely believed myth that Medicare Part D Prescription plans cover some or all the cost of every prescription your doctor gives you. The responsibility of knowing which drugs are covered and which aren’t falls on you, whether you have a stand-alone Part D plan, or your drug coverage is part of a Medicare Advantage plan. The best place to begin is with the Medicare Prescription Drug Benefit Manual.
The list of drugs a plan won’t cover includes:
- 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
- Over-the-counter drugs (purchased without a prescription)
Sometimes there are exemptions, for example, if a medicine is medically necessary. In that case, a plan may make an exception.
Part D plans won’t cover drugs that are not approved by the FDA. One example is desiccated thyroid, which treats hypothyroidism, prevents goiters, and is also given as part of a medical test for thyroid disorders.
Also, if Medicare Part A hospital insurance or Part B medical insurance covers a medication then Part D won’t. Flu vaccinations and IV chemotherapy medications are two examples.
Then, there’s the list of drugs a Part D plan must cover.
- All medications in protected drug classes
- Immunosuppressant (organ transplant)
- Antiretroviral (HIV/AIDS)
- Anticonvulsant (seizures)
- Antineoplastic (cancer)
Finally, there are drugs a plan can choose to cover. Drug plans are required to cover at least two drugs from other categories. It’s in these “other categories” that noncoverage issues begin. For example, beta blockers is a category of drugs. Within that category, a plan might choose to cover atenolol and propranolol, but not metoprolol. Yep, it’s very confusing.
If you find yourself at odds with Medicare’s drug plan policy, what can you do?
If a drug is on the Cannot Cover list, unless there is a medically necessary exception, the only choice is to purchase the drug with a discount care. You will not be reimbursed.
For drugs a plan chooses not to cover:
- If it’s a brand-name drug, ask your doctor if there is a generic option.
- Find out if there are any other prescription drugs in your plan’s formulary that would be effective.
- Your doctor can try a formulary exception, a request to obtain a Part D drug that’s not included in a plan’s formulary. The physician’s statement must prove that the noncovered drug is necessary to treat the medical condition and that no alternatives on the plan’s formulary will work. If the plan denies the request, there is an appeals process.
Finally, you can switch Part D plans if you find one that will cover the drug(s) you need and are looking for. You can switch plans once a year during the Open Enrollment Period, October 15-December 7.