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What Prescription Drugs Does My Medicare Part D Prescription Drug Plan Cover?

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If you’re thinking about enrolling in Medicare Part D, you probably understand that Medicare Part A (hospital insurance) and Part B (medical insurance) generally cover only medications administered during hospital stays and doctor visits. Otherwise, Part A and Part  B usually don’t cover prescription drugs. But you may be wondering “What does Medicare Part D cover?”

What does Medicare Part D cover?

For Medicare prescription drug coverage, you can sign up for either:

  • A stand-alone Medicare Part D Prescription Drug Plan to work alongside your Medicare Part A and Part B coverage
  • Or a Medicare Advantage Prescription Drug Plan

Either type of plan generally covers a sizable number of prescription drugs. The government sets guidelines for which medications plans must cover. Medicare Prescription Drug Plans must cover at least two medications in each therapeutic class. A therapeutic class refers to a group of medications used to treat a particular health condition.

Also, for six therapeutic classes, Medicare Part D Prescription Drug Plans must cover all drugs available in that class. The six “protected” classes include:

  • Anticonvulsants, used to treat epilepsy and other conditions, including mental health conditions
  • Antidepressants
  • Antipsychotics
  • Immunosuppressant medications used to prevent organ transplant rejection
  • Antiretrovirals, used to treat HIV/AIDS
  • Antineoplastics, used to treat cancer

How do Medicare Part D Prescription Drug Plans provide coverage?

A formulary is a list of prescription drugs that a particular Medicare Prescription Drug Plan covers. Formularies may vary plan to plan. However, every therapeutic class of prescription drugs will be covered by all Medicare Part D prescription drug plans. A plan formulary may change at any time. You will receive notice from your plan when necessary.

Medicare Part D Prescription Drug Plans can place medications on different benefit “tiers,” or levels, that have different authorization rules and copayments or coinsurance. Many plans cover common generic and brand-name prescription drugs. A generic will usually have a lower copayment than its brand-name counterpart.

Medicare Part D Prescription Drug Plans might use medication management strategies for safety and cost reasons. Examples of these strategies might include quantity limits, step therapy, and prior authorization requirements.

When you’re comparing Medicare Prescription Drug plans, it’s a good idea to check the formularies and choose the plan that best meets your prescription drug coverage needs.

What doesn’t Medicare Part D cover?

Medicare Part D does not typically cover medications or products not approved by the FDA. Other medications that Medicare Part D generally doesn’t cover include:

  • Non-prescription drugs
  • Medications to control weight or treat anorexia
  • Fertility medications
  • Prescription drugs for cosmetic purposes or hair growth
  • Over-the-counter medications for the relief of cough and cold symptoms
  • Prescription drugs for sexual dysfunction
  • Most prescription vitamins and mineral products

Note:  Some plans may have “enhanced alternative coverage.” This means they may cover some of these excluded prescription drugs.

Would you like to compare Medicare Prescription Drug Plans at your convenience? Just enter your zip code and click the Browse Plans button on this page. You can also call eHealth to talk with a licensed insurance agent.

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