Getting to Know Your Part D Plan’s Drug List

What Medications Are Not Covered by Medicare Part D

Updated on: June 29, 2018

Originally posted on: September 21, 2016
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. The drug list changes each year depending on the rules and guidelines released by the Centers for Medicare & Medicaid Services (CMS) which prescription drug plans (Part D) and Medicare Advantage Plans must follow. These formulary guidelines state that plans must base their decisions on scientific evidence and well-established guidelines to cover today’s most widely used medications. This ensures that beneficiaries like you will be covered by the most commonly used and effective medications available to protect your health.

Although most medications in widespread use are covered by prescription drug plans, there are some that may not be covered because they are covered under Parts A or B or not approved by the Food and Drug Administration. The plan may also elect not to cover a drug because it is either too expensive or there is a generic version available. It will be helpful for you to know this information by checking a plan’s coverage during open enrollment every year.

Check a plan’s formulary to see if your drugs are covered

A formulary is updated because there may be a new drug on the market that is shown to be more effective than another in treating a specific condition. Likewise, there may be lower-cost generic drugs that may have become available over the last year 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 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.

What’s not covered by Part D

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

  • Non-prescription over-the-counter (OTC) drugs
  • 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.

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’s 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. If needed, consider enrolling in a supplemental plan to help you pay for your prescriptions.

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.