Drugs excluded from Part D coverage - Medicare Interactive (2024)

Medicare Part D coverage

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There are certain kinds of drugs that are excluded from Medicare coverage by law. Medicare does not cover:

  • Drugs used to treat anorexia, weight loss, or weight gain
    • Note: Part D may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases
  • Fertility drugs
  • Drugs used for cosmetic purposes or hair growth
    • Note: Drugs used for the treatment of psoriasis, acne, rosacea, or vitiligo are not considered cosmetic drugs and may be covered under Part D
  • Drugs that are only for the relief of cold or cough symptoms
  • Drugs used to treat erectile dysfunction
  • Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
  • Non-prescription drugs (over-the-counter drugs)

Note: Prescription drugs used for the above conditions may be covered if they are being prescribed to treat other conditions. For example, a medicine for the relief of cold symptoms may be covered by Part D if prescribed to treat something other than a cold—such as shortness of breath from severe asthma—as long as it is approved by the U.S. Food and Drug Administration (FDA) for such treatment.

If your doctor prescribes a non-cancer medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless the use is listed in one of three Medicare-approved drug compendia (medical encyclopedias of drug uses). For fighting cancer, your drug plan will draw from these and additional compendia and peer-reviewed medical literature when deciding whether to cover a drug.

You may also receive a denial from your Part D plan stating that your drug does not meet the FDA’s Drug Efficacy Study Implementation (DESI) standards. DESI evaluates the effectiveness drugs that had been previously approved on safety grounds alone. Drugs that are found to be less than effective by DESI evaluation are excluded from coverage by Part D.

Drugs excluded from Part D coverage - Medicare Interactive (2024)


Drugs excluded from Part D coverage - Medicare Interactive? ›

Usually, Part D plans do not cover drugs for weight management, erectile dysfunction, or fertility. Part D plans cover two drugs in the most commonly prescribed categories. However, different policies may offer different drug options.

Which of the following are excluded from coverage under Medicare Part D plans? ›

Usually, Part D plans do not cover drugs for weight management, erectile dysfunction, or fertility. Part D plans cover two drugs in the most commonly prescribed categories. However, different policies may offer different drug options.

Are all prescription drugs covered under Medicare Part D? ›

All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan's list of covered drugs is called a “formulary,” and each plan has its own formulary.

What are the exceptions to the Medicare Part D penalty? ›

For each month you delay enrollment in Medicare Part D, you will have to pay a 1% Part D late enrollment penalty (LEP), unless you: Have creditable drug coverage. Qualify for the Extra Help program. Prove that you received inadequate information about whether your drug coverage was creditable.

How do formulary exceptions work? ›

A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.

What is an excluded drug? ›

A drug exclusion list is a list of medications that will not be covered by a health plan for any reason. The drug is not on formulary and there are no loopholes to gaining approval.

What drugs are covered under Part D Medicare? ›

All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
  • HIV/AIDS treatments.
  • Antidepressants.
  • Antipsychotic medications.
  • Anticonvulsive treatments for seizure disorders.
  • Immunosuppressant drugs.
  • Anticancer drugs (unless covered by Part B)

What is the maximum out-of-pocket for Medicare Part D in 2024? ›

Out-of-pocket prescription drug costs after the new reforms

In 2024, after paying the initial deductible, a person on Medicare will pay 25 percent of drug costs. They will have a cap of about $3,300 and will no longer pay five percent of drug costs in the catastrophic phase.

What are Tier 6 drugs for Medicare? ›

Tier 6 Drugs

Tier 6 prescriptions might include weight loss, hair loss meds, Viagra, or drugs for certain specific medical conditions. If the Part D coverage is designed with certain health conditions in mind, medications related to those conditions might be included in Tier 6.

What is the out-of-pocket maximum for Medicare Part D? ›

Out-of-pocket costs

Health or prescription drug costs that you must pay on your own because they aren't covered by Medicare or other insurance. will be capped at $2,000, starting in 2025.

What is a Part D exception? ›

You may request an exception from your Medicare prescription drug plan if: You are taking a drug that has been removed from the plan's formulary. A non-formulary drug is prescribed and medically necessary. The copayment for a drug you are taking increases and you cannot afford it.

How do I get rid of Part D penalty? ›

Eliminating the Part D LEP
  1. If you receive Extra Help, your penalty will be permanently erased.
  2. If you are under 65 and have Medicare, your LEP will end when you turn 65.
  3. If you qualify for a state pharmaceutical assistance program (SPAP), it may pay your penalty for you.

How to determine if prescription drug coverage is creditable? ›

Creditable coverage: A health plan's prescription drug coverage is creditable when the amount the plan expects to pay for prescription drugs for individuals covered by the plan in the coming year is, on average, the same or more than what standard Medicare prescription drug coverage would be expected to pay.

Can you ask your insurance to make an exception with a medication? ›

When faced with uncovered medications, you have an option to file a formulary exception with your insurance to request that they allow you coverage for the medication. – Your doctor is your ally on this. Most plans require that your doctor submit a formulary exception on your behalf.

How long does a formulary exception take? ›

Once submitted, your doctor should hear back about your plan's decision within a couple days after the request. If approved, your medication will be covered at cost-sharing that applies in the lower tier.

What does it mean if a drug is removed from formulary? ›

First, understand that your health plan isn't saying you can't have the drug your healthcare provider prescribed. Instead, excluding a drug from its formulary is more like saying that it won't pay for that particular drug. You may still have it if you or someone else pays for it.

Which of the following is not covered by Medicare? ›

Medicare medical insurance does not cover routine eye or hearing examinations. Neither does it cover hearing aids, eyeglasses, or contact lenses, except for lenses required following cataract surgery.

What are the 6 things Medicare doesn't cover? ›

Some of the items and services Medicare doesn't cover include:
  • Long-term care (also called. custodial care. Custodial care. ...
  • Most dental care.
  • Eye exams (for prescription glasses)
  • Dentures.
  • Cosmetic surgery.
  • Massage therapy.
  • Routine physical exams.
  • Hearing aids and exams for fitting them.

What is covered in Medicare Part D quizlet? ›

Medicare Part D help cover the cost of prescription drugs, is run by medicare approved insurance companies, may help lower prescription drug costs, and may protect against higher costs in the future.

Does Medicare Part D cover Jardiance? ›

While most Medicare Part D plans cover Jardiance, specific plan formularies and out-of-pocket costs vary. Prescription drug plans come with different costs, including monthly premiums, annual deductibles, copayments, and coinsurance.

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