Medicare Part D is an outpatient prescription drug benefit available to people who have Medicare (Part A and/or Part B).
While technically Part D is optional coverage, Medicare “encourages” you to enroll in Part D by assessing a late penalty if you don’t.
Sometimes there are legitimate reasons not to enroll in Part D.
Maybe you are still working and have drug coverage through your employer plan. Or perhaps you have VA drug coverage and don’t mind getting your medications filled there. In these instances, you have creditable coverage for Part D purposes, which is as good or better than what Part D would provide.
Medicare contracts with private plans to offer drug coverage under Part D. There are two ways to enroll in Part D. You can purchase a stand-alone Part D plan or enroll in a Medicare Advantage plan that includes Part D.
Part D plans can cover:
- FDA approved prescription drugs
- Certain supplies associated with the injection of insulin (such as syringes, needles, alcohol swabs, and gauze).
Medicare has a few rules about Part D drug coverage that the drug plans must follow (such as covering at least two drugs in every category or drug class with broader requirements for the following types of drugs: anti-rejection, antidepressants, antipsychotics, anticancer, anticonvulsants, and drugs used to treat HIV/AIDS).
Plans decide which drugs will be covered on their formulary (list of covered medications) and whether there are any special rules a person must follow in order to get a medication covered by the plan (such as prior authorization, quantity limits, or step therapy requirements ).
MEDICARE PART D EXCLUDED DRUGS
The following types of medications are currently excluded by law from standard Part D coverage (but Enhanced” Part D plans may cover these medications):
- Benzodiazepines (such as Ativan)
- Barbiturates (such as Valium or Phenobarbital)
- Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
- Over-the Counter medications
- Anorexia, weight loss or weight gain
- Cosmetic purposes or hair growth
- Relief of symptoms of colds, like a cough and stuff nose
- erectile dysfunction
Please note that individuals who have Medicare and full benefits through Medicaid, the ACCESS card may cover some drugs that are excluded by Medicare Part D.
Some drugs may require prior authorization before ACCESS will cover them.
Certain prescription drugs in these categories may also be covered by Part D if they are being prescribed to treat other conditions. For example, some medications used to treat cough and colds may also be prescribed to treat allergies.
If the FDA approves of the use of these medications for other conditions, then Part D plans may cover them.
Part D plans will also not cover drugs that are covered by Medicare Part A or Medicare Part B.
Medicare Part A covers:
- Medications administered while an individual is an inpatient in the hospital
- Medications administered while an individual is in a Medicare-covered nursing home stay
Medicare Part B covers:
- Medications that are administered in a doctor’s office (like chemotherapy)
- Certain oral anti-cancer medications
- Certain vaccines (such as COVID-19, Influenza and Hepatitis B)
- Certain medications that are administered by Medicare-covered Durable Medical Equipment (like a nebulizer or an external pump)
- Immunosuppressants (anti-rejection medications for patients who had a Medicare-covered transplant
MEDICARE PART C AND OVER-THE-COUNTER MEDICINES
Most Medicare Advantage (MA) plans now include Part D coverage and roughly 80 percent of MA plans cover over-the-counter (OTC) medicines, vitamins, and supplies.
Over-the-counter medicines are those you can buy at the store without a prescription from your doctor.
Most MA plans give enrollees an allotted amount – usually per month or per quarter. They can purchase approved products from a catalog.
Don’t overlook this benefit because it could be worth $400 per enrollee per year.
Remember OTC drugs are excluded under Original Medicare and Medicare Part D.
(Joel Mekler is a certified senior adviser. Send him your Medicare questions at firstname.lastname@example.org.)