With Medicare Part A covering the drugs you need under your hospital or nursing care and Medicare Part B covering most drugs administered by your provider or facility, what drugs are covered by Medicare Part D?
Sure, it may seem a little confusing, but fear not; we’re here to help you understand Medicare Part D prescription drug plans, what they cover and how they benefit you on your health care journey.
What is Medicare Part D?
Medicare Part D is outpatient prescription drug coverage, and while Medicare Part B may have limited prescription drug coverage for outpatients, Medicare Part D is a plan that “takes over” where Part B leaves off. Not all outpatient prescriptions may be covered.*
It covers every therapeutic category of prescription medications for outpatients, including antidepressant, antipsychotic, anticonvulsant, antiretroviral (AIDS treatment), immunosuppressant and anticancer, and it must cover all drugs in these categories. It also needs to cover at least two drugs in most other categories.
It’s covered by Medicare through private insurance companies in partnership with Medicare, and each plan has its own formulary (list of prescription drugs) available under it.
While Medicare Part D is sometimes included in Medicare Advantage plans, you may also purchase it as a stand-alone Part D coverage plan. It is available through private companies, either as a stand-alone for those with Original Medicare or as part of the full benefits offered under the Medicare Advantage plan.
If you have creditable drug coverage, there may be a special enrollment period for you. Otherwise, you should enroll in Medicare Part D when you first get Medicare.
Who Would Need Medicare Part D?
While the different parts of Medicare (i.e., Medicare Parts A, B, C and D) can be put together in many ways to provide coverage based on your needs, Medicare Part D is used by those who need coverage not included in other Medicare plans.
For instance, Medicare Part D may cover transplant and immunosuppressive drugs that are NOT covered by Medicare Part B, and those who have end-stage renal disease (ESRD) and are on Original Medicare may also join a Part D drug plan.
By exploring the plans, you can determine the cost sharing (i.e., copayment or co-insurance), management requirements, authorizations and quantity limits that best fit your needs under Medicare Part D.
Which Prescription Drugs are Covered?
Though a plan’s formulary, or list of drugs covered by Medicare Part D, varies from plan to plan, every therapeutic category of prescription drug must be covered under Part D.
These categories include:
- Antiretrovirals (AIDS treatment)
Additionally, Medicare Part D formularies must also cover at least two drugs in most prescription drug categories.
It should also be noted that, in the event that a noncovered drug is deemed medically necessary for you, every Medicare Part D plan is required to allow a process for its members to request exception to their plan’s formulary. This can also be applied to other areas of the plan, such as quantity limits.
Which Generic Drugs are Covered by Medicare Part D?
While some Medicare Part D plans cover brand-name drugs, others specialize in, or may include access to, generic prescription drugs. This is also reflected in the plan premium, which may be higher for plans covering brand-name drugs than it may for those covering generic drugs only.
While not all drugs on the market are available in generic form, FDA regulations state that generic drugs that are available must be identical to brand-name drugs in dosage, form, safety, strength, route of administration, quality and performance characteristics. They are also required to have the same active ingredient as their brand-name counterpart, and drug makers need to prove the drug’s efficacy as being the same as the brand-name version.
But while not all prescription drugs are available in a generic version, there may be generic drugs your doctor can prescribe that are similar to a brand-name medication. These versions can often be used in place of an expensive brand-name version to help keep things affordable for you.
What is the Medicare Drug Plan Tier System?
To accommodate all budgets and needs, plans may offer tiered formularies. While tiers may be divided differently from plan to plan, lower tiers generally represent less costly medications, and upper tiers covering higher-cost brand-name options.
Though your plan’s tier system may be different, here is an example of how one might work:
- Tier 1 is the lowest copayment option and likely consists of mostly generic prescription medications.
- Tier 2 is a medium copayment option and may represent preferred brand-name prescription drugs.
- Tier 3 is a higher copayment, with nonpreferred brand-name prescription drugs
- Tier 4, or Specialty Tier, is the highest copayment and represents the highest-cost prescription medications
But there are exceptions to this, such as if your health care provider feels you need a drug from a higher tier group, rather than a similar one in a lower group. In this case, you or your doctor may ask for an exception for a lower copayment for an upper-tier drug. This needs to go along with a supporting statement from your doctor or prescriber describing the medical reason for the higher-cost drug.
But no matter your income level or prescription drug needs, Medicare Part D is likely to have a plan to fit them.
Why Choose a Provider at Intermountain Health?
While the medical professionals at Intermountain Health will gladly help you understand your Medicare Part D plan, our obligation to you hardly stops there. That’s because our commitment is in serving you and your community, to which we bring our 45-plus years of affordable, top-quality healthcare to help you live the longest, healthiest life possible.
We rank in the top five of U.S. healthcare systems in quality, affordability and innovation, which shows our dedication to ensuring top-quality health care is conveniently available to you at a cost that fits your budget.
Ready to put your health care needs into the best possible hands? We’re here to ensure that happens throughout every step of your medical journey.
After all, at Intermountain Health, your needs come first each and every time, and that’s our promise to you.
*Please check with your plan for more information on details of your benefits coverage. This article is for informational purposes only and is not intended to be a substitute for medical advice or diagnosis from a physician or qualified healthcare professional.