Which drugs are not covered by Medicare?

If you have Medicare coverage that includes prescription medication, getting to know your drugs list, or formulary, will help you understand the drugs covered on your plan.

To have drug coverage, you will need Medicare Part D. This is available through private medical insurers, and you can buy this as part of Medicare Advantage or as a stand-alone drug plan.

Medicare Parts A and B drug coverage

Medicare Part A covers your inpatient care, and Medicare Part B covers outpatient treatment. They form part of the national health insurance program available to people over 65 years and those under 65 with specific medical conditions. Together, they’re known as original Medicare, and they offer limited drug coverage.

Part A covers medications needed during a Medicare-covered stay in a hospital or skilled nursing facility.

Part B covers some outpatient prescription drugs at a doctor’s office or hospital outpatient setting. Typically, this is medication a doctor or healthcare professional will administer.

To add more drug coverage to original Medicare, you can purchase Medicare Part D from a Medicare-approved private insurance company. Although Medicare Part D has broad coverage, it doesn’t include all medications.

Medications not covered by Medicare Part D

Many drugs are available through Medicare Part D. However, as private companies offer this coverage, not all plans cover all drugs, and some may cover a different drug selection.

Whichever insurance provider you choose, there are some medications that Medicare Part D rarely covers. These include:

• drugs already covered by Medicare parts A and B
• over-the-counter or nonprescription medications
• fertility drugs
• medications for erectile dysfunction — Medicare Part D may cover these if they have Food and Drug Administration (FDA) approval to treat other conditions
• most prescription vitamins and minerals, except some fluoride preparation products and prenatal vitamins
• drugs a manufacturer provides that testing services monitor
• medications for weight loss or weight gain

If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. Follow the links on drug names for savings on that medication, or search for a specific drug here.

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

If your doctor prescribes a drug that Medicare Part D doesn’t cover, there are a few things you can do:

• Check for generics: Your plan may cover a generic version of the prescribed drug. You can check with your doctor if you would benefit from this generic version.
• Check for alternatives: Consider asking your doctor if a different medication would be effective for your condition, and if so, check this against your formulary.
• Ask for an exception: You can ask your medical insurance company if they will make an exception to your formulary and cover the recommended medication. Include a written statement from your doctor confirming that the drug is medically necessary and suitable for your condition.
• Consider switching plans: You could also consider looking for and switching to a new plan that covers the medication you need. You can only make this type of change during Medicare open enrollment in the fall, which runs from October 15–December 7, and coverage will start on January 1 of the following year.
• Pay out of pocket: If your insurance won’t cover the drug and you cannot change plans, you may be able to cover the cost yourself. Check whether you qualify for Medicare Extra Help.
• Use the Optum Perks Discount Card or mobile app: If you need help covering the cost of medications, the free Optum Perks Discount Card could help you save up to 80% on prescription drugs. You can search for a specific drug here.

Summary

Original Medicare, Parts A and B, offer minimal drug coverage and usually only during a hospital stay or while at the doctor’s office.

You can purchase the Medicare Part D prescription drug plan as part of Medicare Advantage (Part C) or as a stand-alone plan. This will provide more drug options, although covered medications often vary per insurer.

If a Medicare Part D plan doesn’t cover the drugs a doctor has prescribed, you can ask your insurer to make an exception or use the Optum Perks Discount Card or mobile app to help you save money.

Download the free Optum Perks Discount Card to save up to 80% on some prescription medications.