Drug Coverage: Some Important Rules You Should Know


All Medicare Prescription Drug plans have a number of rules, created to meet the needs of beneficiaries and, at the same time, to protect plan providers.  

 One of the rules for most Medicare drug plans is that they need to cover two drugs, minimally, in each drug category. They also need to cover almost all drugs in the anit-psychotics, anit-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS classes.  Additionally, even when a Medicare drug plan doesn’t have a certain drug on its formulary, another drug with a comparable function which is equally effective will likely be covered.

The plans are usually able to choose which of the drugs in each category they will cover.  There are also a number of drugs your plan probably won’t cover, like barbiturates, benzodiazepines, and weight control drugs, although some plans may.  Most often, your drug plan won’t cover over-the-counter medication.  There are, of course, exceptions, like if your state allows people with Medicaid to receive coverage for these over-the-counter drugs.

Plans must, regardless of which Medicare Prescription Drug plan you are enrolled in, have some sort of a process which allows you to request coverage for a necessary drug not included in their formulary.

Drug plans also have some stipulations to ensure correct coverage use, such as you and/or your doctor needing to contact the plan prior to prescription coverage, demonstration of the medical necessity of the drug, a limit on how many drugs you can get at once, and “step therapy”, which is trying one or more similar, low-cost drug before moving on to a more expensive brand-name version. 

Because formularies vary according to plan and because they may change, each plan will have the required up-to-date information you need.  To find out what drugs are covered by your Medicare Drug Plan, contact your plan directly. 


Submit Your Comments or Questions Here