Medicare Part D Drugs: Covered and Excluded Drugs in a Part D Drug Formulary

Because Medicare Part D plans that cover prescription drugs are privately insured, each Medicare Part D plan may be different. The insurance company decides which drugs to cover under its Part D plan and at what benefit level.

The different levels of covered drugs under the Part D plan are called "tiers." The tiers represent how much you pay out of pocket for the Part D drugs listed in that tier. For example, you may have one tier for generic drugs, another for brand-name drugs and maybe even a third tier for preventive drugs used to control certain medical conditions.

This list of Part D drugs is called a "formulary" and is a list of drugs that the Part D plan prefers you to buy. Generally, a Part D plan covers drugs that cost less at a higher level, meaning you pay less out of pocket. This encourages you to ask your doctor to prescribe drugs that are on your Part D plan's formulary. Usually, generic drugs are the least costly.

Changes in a Part D formulary list of drugs

Each Part D plan is required to publicly publish its formulary, list of drugs. You can usually find it on the Part D insurer's website. The Part D plan must also tell you when it removes drugs from the Part D formulary.

Part D plans are restricted from making changes to the listed drugs - or changing the Part D tiered pricing - between the beginning of the Part D plan's annual election period until 60 days after the Part D plan coverage begins. The exception to this is if the FDA determines a Part D drug is unsafe or a manufacturer removes a Part D drug from the market.

Midyear changes to formulary drugs are limited and Part D insurers must notify you. This mailing includes: name of drugs, Part D change type (e.g., add/remove/tier change), reason for the change, alternate drugs, new Part D cost sharing, and exceptions.

Drugs covered under Medicare Part D

Medicare Part D plans cover all commercially-available vaccine drugs when medically necessary to prevent illness.

Otherwise, the Part D insurer decides which drugs to cover, which drugs not to cover, and under which tier to cover them. Before enrolling in a Medicare Part D plan, you should review the Part D plan's formulary to see which drugs it covers.

What drugs are not covered under Medicare Part D?

Since the Part D insurer decides which drugs not to cover, this list cannot possibly be complete. However, Part D plans usually do not cover the following drugs:

• Drugs that are otherwise covered under Medicare Part A or Part B
• Drugs, or classes of drugs that are restricted under Medicare, such as:
  • Weight loss or weight gain drugs
  • Fertility drugs
  • Drugs for cosmetic purposes or hair growth
  • Nonprescription drugs
  • Barbiturates
  • Drugs for sexual or erectile dysfunction

Your Medicare Part D rights

If you have a Medicare Part D plan for prescription drugs, you have the right to the following:

• a. "Coverage determination" - a written explanation from your Medicare Part D plan about your benefits, including: how drugs are covered, your costs for drugs, any coverage requirements (such as drugs that require the Part D plan's prior authorization) and requirements for making coverage exception.
• b. Ask for exceptions to drugs not covered by your Part D plan's formulary.
• c. Ask for exceptions to waive Part D plan coverage rules (e.g., prior authorization).
• d. Ask for exceptions for a lower copayment if you think you should pay less for higher-cost drugs because you or your prescriber thinks you cannot take any of the lower-cost drugs for the same condition.

Medicare has neither reviewed nor endorsed this information.