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Prescription drug coverage is an important benefit for Medicare recipients. Medicare Prescription Drug Plans (Part D) may be purchased from private insurance companies that are contracted with Medicare to provide and manage prescription benefits to beneficiaries. Seniors who choose Original Medicare can purchase a standalone Medicare Prescription Drug Plan; those who are enrolled in a Medicare Advantage Plan typically have their Part D needs met there. Every Part D Plan and Medicare Advantage Plan must provide certain types of prescription drugs in its formulary, but the list of specific drugs that are covered is ultimately up to the insurance company.
While certain drugs must be covered under Medicare, there is also a list of drugs that are never covered by Medicare for various reasons.
Drugs not covered by Medicare
A Part D-covered drug must be FDA-approved, prescription medication with a compendial indication. Based on this definition, there are many drugs that Medicare plans will not cover under Medicare Part D. The list includes:
Non-prescription drugs
Non-FDA-approved drugs
Drug efficacy study implementation (DESI) drugs
Drugs that assist with fertility
Drugs for weight management, including anorexia, weight loss or weight gain
Prescription vitamins and mineral products (prenatal vitamins and fluoride preparations are an exception)
Drugs prescribed for cosmetic purposes or hair growth
Drugs that provide relief of cough and cold symptoms
Drugs for sexual dysfunction
Devices such as diaphragms
Bulk chemicals in the following STCs: U6I, U6Q, U6U, U6W, and U6X and any that do not meet the definition of a Part D-covered drug
Ingredient/adjuvant (sterile water for injection)
Line flush with normal saline IV flush or Heparin Sodium Lock Flush
Medical supplies such as ethyl alcohol and Biafine
Any drugs covered under Medicare Part A or Part B
What to do if your Part D plan doesn’t cover a Medicare approved drug you are taking
If your prescription drug plan doesn't cover a Medicare approved drug that you're taking, you have several options:
1. Fill a temporary supply
2. Ask your doctor about switching to a different drug that is covered on your plan’s formulary
3. Contact the drug manufacturer to see if they have a program to cover some or all of the cost of prescriptions that are not covered by insurance
4. Contact your plan to ask for an exception for your prescription drug
5. Apply for Extra Help to help pay for some to almost all of the cost of your prescription drugs (speak to your Medicare agent to see if you qualify)
6. Apply for Hawaii SPAP. The Hawaii State Pharmacy Assistance Program provides financial assistance to elderly Hawaii residents that do not qualify for Medicaid or have other prescription drug coverage.
7. Check to see if your (or your spouse’s) retiree drug coverage will pay for gaps in your Part D coverage
8. Upgrade to an enhanced Part D plan. If you are in need of expensive prescription drugs then it may be worth it to purchase an enhanced Part D plan. These plans usually come with higher monthly premiums but in exchange they offer more benefits; some even cover excluded drugs.
There are many prescription drug plans available to seniors on Medicare. If you require certain prescription medications, be sure to sign up for a plan that covers them. Ask your Medicare agent for help!
Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.
At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.