While some prescription drugs are covered under Medicare Part B, the majority of the drug coverage one likely will need will be through Medicare Part D. Unlike Medicare Parts A and B, Medicare Part D must be purchased through a private health insurance company contracted with the government. Prescription drugs covered under Medicare Part D include outpatient prescription medications that are included on the plan’s formulary list, and purchased from a pharmacy in the network.
A formulary list is a list of approved prescription drugs covered under Medicare Part D. If the prescription drug you need is not on the formulary list, the prescribing physician may be able to have an exception made, provided the drug in question is not one of the drugs excluded by law from Medicare Coverage.
Medicare Part D providers are not required to cover all prescription drugs. Prescription drug coverage under Medicare Part D plans vary widely. It is important you know what your individual needs are before you enroll in any Prescription Drug Plan. (PDP) Even the drugs that are covered under a specific Medicare Part D plan may not be covered entirely or for the entire year. This can create a gap in coverage can be a financial strain on individuals already struggling on a limited income. Supplemental gap insurance may be needed to cover excessive prescription costs.
If you are already on Medicare Part A and B and desire prescription drug coverage you must enroll in a Medicare approved Prescription Drug Plan during the yearly enrollment period. Enrolling in
any Medicare PDP outside the open enrollment period may mean added penalties.
Individuals already in a Medicare Advantage Plan, also known as Medicare Part C, must enroll under that Medicare Advantage Plan provider for a Prescription Drug Plan. The exception would be if the Medicare Part C provider you are using doesn’t have a PDP. If that is the case you have the option of finding a Medicare Part C provider that does and switching to a new provider or going to the original Medicare Plan Part A & B and enrolling in an accepted PDP.
Medicare coverage changes rapidly. Compare Prescription Drug Plans to find the one covering your prescription drugs before enrolling.
Anytime Medicare denies coverage of a particular prescription drug, you are entitled to make a request for an exception. This request must be made with the assistance of the prescribing physician.