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What does Medicare Part D cover?

What does Medicare Part D cover?

You have likely heard a lot about this plan, but what specifically does Medicare Part D cover?

The list of drugs covered by Part D is called the formulary. The formulary may change between plans. For this reason, members choose their Medicare Part D Plan based on medications they’re already taking.

To make sure that members have access to medication for a wide range of conditions, Medicare reviewed the categories and classes of drugs patients use the most. An insurance company offering Medicare Part D must offer at least two prescription medications out of each category. While they must provide options within each category, each provider has autonomy in choosing which drugs are covered and which are not.

Formularies Can Change

A variety of circumstances could cause a provider to update its formulary. Medicare may update its guidelines, new drug therapies may emerge, or a manufacturer may decide to discontinue a certain drug. The FDA may re-classify a drug or find it unsafe based on new information. It’s also possible for a brand name drug to become newly available. In this case, the plan is allowed to update their formulary to offer the generic version rather than the brand name.

In the event that a plan removes a drug you’re taking from its formulary, it must provide you at least a 30 day notice of the upcoming change. It will also be required to offer your next refill with at least a 30 day supply of the medication you’d been taking.


Generic vs Brand Name

Medicare Part D prescription drug plans offer different ‘tiers’. The lowest tier is generally the lowest co-payment for generic drugs (when available). The second tier would be a higher co-payment for mostly brand name drugs. The next tier up may offer more brand name drugs or very expensive drugs but also come with a higher co-payment.

When it comes to generic versus brand name, there are certain conditions that must be met by the generic drug manufacturer.

What Does Medicare Part D Cover–Active Ingredient-White

Must specifically match the dosage and strength by using the same active ingredient.

What Does Medicare Part D Cover–Quality and Safety-White

Must have the same quality and safety guidelines.

What Does Medicare Part D Cover–Condition-White

Must be for the same condition and administered in the same fashion as the brand name drug.

What Does Medicare Part D Cover–Performance-White

Must have matching performance characteristics between both drugs.

Once the generic drug manufacturer has proven the criteria to the FDA, the drug is offered as a generic alternative to its brand name counterpart.

What if I need a drug that isn’t covered under any available plan?

More often than not, your plan will offer something similar that will work for you. If your prescribing doctor knows a specific reason why the drugs listed in the plan’s formulary will cause you harm or not meet your needs, you can request an exception.

Also remember that you are still allowed to get prescriptions that are not listed in your plan’s formulary. If you were unable to get an exception, you will have to cover the expense of the medication.

The best course of action you can take to find out if the drugs you are taking are covered under a Medicare Part D Plan is to schedule a consultation with a health insurance provider in your area.