Drugs not covered by medicare insurance

Sometimes, people enrolled in Medicare may find that their insurance doesn’t pay for a drug that their doctor has prescribed. Knowing what is covered and not covered by Medicare can help you navigate your options. 

Medicare parts A and B drug coverage 

Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) are national health insurance programs available to people over 65. Together, they’re known as original Medicare. They only offer some drug coverage: 

  • Part A only covers medications needed during a Medicare-covered stay in a hospital or skilled nursing facility.
  • Part B only covers some outpatient prescription drugs at a doctor’s office or hospital outpatient setting. Typically, this is medication you wouldn’t administer yourself. 

To add more drug coverage to original Medicare, Medicare Part D can be purchased from a Medicare-approved private insurance company. Although Medicare Part D, also known as the Medicare prescription drug program, has broad coverage, it doesn’t cover all medications.

Medications not available with Medicare Part D  

Many drugs are available through Medicare Part D coverage. However, because Medicare Part D coverage is offered through private companies, not all plans cover all drugs. Plan pricing and formularies, or lists of drugs covered by the plan, vary by company.

No matter which insurance provider you choose, there are some medications that are rarely, if ever, covered by Medicare Part D. These include:

  • Drugs already covered by Medicare parts A and B
  • Over-the-counter nonprescription drugs
  • Fertility drugs
  • Drugs for erectile dysfunction (Note: Medicare Part D may cover these drugs if approved by the FDA to treat other conditions.)
  • Most prescription vitamins and minerals (Note: Medicare Part D does cover fluoride preparation products and prenatal vitamins.)
  • Drugs provided by the manufacturer that must be monitored by testing services

What if your Medicare Part D plan doesn’t cover a drug you need? 

If your doctor prescribes a drug that isn’t covered by your Medicare Part D plan, there are a few things you can do:

  • Check for generics. Your plan may cover a generic version of the drug you need. Ask your doctor if a generic drug would work for you.
  • Check for alternatives. Ask your doctor if a different medication would be effective for your condition. If so, check to see if it’s available on your Medicare Part D plan formulary.
  • Ask for an exception. See if your insurance company will make a formulary exception and cover the medication. With your request, you should include a written statement from your doctor indicating that the drug is medically necessary.
    • Appeal a “no.” If your insurance company won’t make a formulary exception, consider filing a request for a new decision. According to the Centers for Medicare & Medicaid Services, there’s a 5-level appeals process:
      • Level 1: Redetermination from your plan
      • Level 2: Review by an independent review entity
      • Level 3: Decision by the Office of Medicare Hearings and Appeals
      • Level 4: Review by the Medicare Appeals Council
      • Level 5: Judicial review by a federal district court
  • Switch plans. Find a plan that covers the drug you need and make a change. Keep in mind that you can only make this type of change during fall open enrollment (October 15 to December 7), and that coverage will start January 1 of the following year.
  • Pay out of pocket. If your insurance won’t cover the drug, you may be able to cover the cost yourself. Check to see if you qualify for Medicare Extra Help, or use Optum Perks to save.

Takeaway  

Original Medicare (Part A and Part B) offers minimal drug coverage under limited conditions. You can purchase the Medicare prescription drug plan (Part D) for much broader coverage. Medicare Part D plans are offered by private insurance companies. They vary from plan to plan as far as what they cost and what they cover.

If your Medicare Part D plan doesn’t cover a drug prescribed by your doctor, you have a few options, including asking your plan to make an exception in your specific case and using Optum Perks.