Getting to Know Your Part D Plan’s Drug List

What Medications Are Not Covered by Medicare Part D

Updated on: October 4, 2019

Originally posted on: September 21, 2016
by
The Roadmap for Medicare staff specialize in all topics related to Medicare Part D, choosing a Medicare plan, and making smart health decisions in retirement.

A plan’s drug list or “formulary” is an important consideration when choosing your Part D coverage. This drug list changes each year depending on the rules and guidelines established by the Centers for Medicare & Medicaid Services (CMS) which prescription drug plans (Part D) and Medicare Advantage Plans must follow.

Each plan must give at least a standard level of coverage, but the list of prescription drugs they cover and how the drugs are covered can vary greatly.

Based on CMS rules, plans must base their decision to include or exclude a drug from their list of covered medications using scientific evidence and well-established guidelines. This ensures that beneficiaries like you will be covered by the most commonly used and effective medications available today. For updated information regarding next year’s Medicare Part D prescription drug plan coverage parameters, please visit medicare.gov.

Although most medications in widespread use are covered by prescription drug plans, there are some that may not be covered. The decision not to cover the medication may be because they are covered under Medicare Part A or Part B, or not approved by the Food and Drug Administration (FDA). A plan may also elect not to cover a drug because it is either too expensive or there is a generic version available. It is helpful to know which drugs are covered and which are not before you enroll in a Part D plan. You can do this by carefully checking a plan’s list of covered drugs during the open enrollment that happens every year.

Check a plan’s formulary to see if the drugs you use are covered

Formularies are updated because there may be new drugs that have shown to be more effective than others in treating a specific condition. Likewise, there may be lower-cost generic drugs that may have become available and are just as safe and effective as the brand-name option.

Although changes in your plan’s formulary may result in a certain drug no longer being covered, rest assured that the formulary will have other drugs available for that condition that are just as effective.

To prepare for any changes in your plan’s formulary that may impact your access to the medications you regularly take, you should make a list of your prescriptions and review them against each plan’s formulary during open enrollment. This will aid you in evaluating which plan is better suited to your needs.

For 2019 and beyond, certain plans can immediately remove brand-name drugs from their formularies and replace them with new generic drugs. These plans can also change the cost or coverage rules for brand-name drugs when adding new generic drugs. If you are taking these drugs, your plan will notify you of any coverage changes.

What’s not covered by Part D

There are certain medication categories that are excluded from coverage under Medicare Part D. These include:

  • Non-prescription drugs, also known as over-the-counter (OTC) medications
  • Drugs used for weight loss or weight gain
  • Drugs used for cosmetic purposes or hair growth
  • Medications used for cough and cold symptoms
  • Sexual or erectile dysfunction medications (unless prescribed for a medically accepted indication)
  • Most prescription vitamins and mineral products

If you take any of these types of medications regularly, be sure to include their cost in your budget. Knowing what to expect will not only help you select the right plan, but also allow you to understand and project for your out-of-pocket costs.

Effective January 1, 2021, CMS will require the Explanation of Benefits that Part D plans send members to include drug price increases and lower-cost therapeutic alternatives. This will help you understand the alternatives available to lower your out-of-pocket costs by considering lower-cost medications.

Formulary exceptions

In some cases, a plan can make exceptions to its drug list if there is a prescription medicine that you take because you’ve tried others and they don’t work for you. Exceptions to the formulary are possible when a doctor writes to the plan to explain why you are not able to take a generic or another brand drug for your condition.

If your medicine is not included in your plan’s formulary, talk with your doctor to determine if your condition requires that you have access to that specific drug. If that is the case, your doctor can request a coverage decision from your plan to try to obtain an exception to provide you access to that medication.

Prepare a roadmap to make sure you have access to the medications you need

Be proactive and educate yourself during open enrollment to understand which medications are covered by your Part D plan. Remember to do this every year to make sure your current plan is still appropriate for your needs.

To learn more about the different coverage stages for Part D and how your medications impact your stage of Medicare coverage, please watch this video.