What do Medicare Part D drug plans not cover?
Medicare Part D prescription drug plans cover many prescribed medications. However, coverage may not be available in some instances. This could be due to drug type, cost, or regulation.
Original Medicare includes Part A, which covers the medications a person receives when they are an inpatient at a hospital, and Part B, which covers limited outpatient drugs, such as those that a doctor administers in their office.
For other types of take-home prescribed drugs, a person must have Part D coverage.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
About Part D
Medicare Part D is optional prescription drug coverage available to those with Original Medicare. Private Medicare-approved insurance companies administer these plans.
When it comes to coverage, the federal government sets guidelines for insurance companies to follow, but the companies can decide which drugs their plans will cover. The lists of drugs covered may often vary.
Costs for Part D plans also vary. If an individual enrolls after their initial enrollment period, for example, the monthly premium will include a permanent late enrollment fee.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Drugs not covered by Medicare Part D
In general, most Part D plans do not cover:
drugs for hair growth
fertility drugs
over-the-counter drugs
medications covered by Medicare Parts A and B
medications for erectile dysfunction
weight management medications
Part B vs. Part D drug coverage
Medicare Part B covers a limited range of drugs under specific circumstances, including:
certain medications for transplants
medications for end stage renal disease
flu and pneumonia shots
immunosuppressants
injections for osteoporosis
medications to be used at home with durable medical equipment, such as a nebulizer
Part D covers a much broader range of prescription medications that an individual takes at home. These include:
medications to manage asthma, heart disease, and high blood pressure
About formularies
Part D plans have lists of covered drugs. These lists, called formularies, divide drugs into different tiers. Usually, a person will pay less for medications classified in lower tiers.
Plan providers must make their formularies available so that people can compare their drug availability.
Medicare rules require Part D plans to cover at least two drugs in the most commonly prescribed categories. Often, this will be a brand-name drug and its generic version, which is typically more affordable.
Each plan can differ and not cover the same medications. This means that a person may have a particular drug covered in one Part D plan but not another.
Plans may change their formulary at any time. However, the plan provider must notify an individual at least 60 days before making a change.
Costs
The 2024 costs for Medicare Part D may differ depending on the plan a person chooses. For example, they may have different monthly premiums, deductibles, and copayments. Charges can also change from year to year.
Plan premium costs depend, in part, on a person’s income. Individuals who earn above a specific amount may need to pay a higher monthly premium.
Premium changes are called Income-Related Monthly Adjustment Amounts (IRMAAs), and Medicare bases this information on a person’s tax returns from 2 years ago. For example, a person’s tax return from 2022 will determine their 2024 premium.
A person pays their IRMAA directly to Medicare and pays their plan premium to the private insurer.
Income brackets and cost information for 2024 are as follows:
Individual filing | Filing a joint return | 2024 cost |
|---|---|---|
$103,000 or less | $206,000 or less | plan premium |
above $103,000 and up to $129,000 | above $206,000 and up to $258,000 | $12.90 + plan premium |
above $129,000 and up to $161,000 | above $258,000 and up to $322,000 | $33.30 + plan premium |
above $161,000 and up to $193,000 | above $322,000 and up to $386,000 | $53.80 + plan premium |
above $193,000 and less than $500,000 | above $386,000 and less than $750,000 | $74.20 + plan premium |
$500,000 or above | $750,000 and above | $81.00 + plan premium |
Rules
Plan providers follow Medicare rules for out-of-pocket expenses, coverage gaps, and deductibles.
For 2024, Medicare implemented the following rules:
Deductibles: No Part D plan may have a deductible that costs more than $545.
Coverage gaps: Individuals move into the coverage gap once they have spent $5,030. The coverage gap is the phase that occurs after a person and their plan cover a certain amount of drug costs.
Out-of-pocket maximum: The maximum amount a person will pay out of pocket is $8,000. After someone reaches their out-of-pocket maximum for the year, they move into the catastrophic coverage phase, and costs will significantly decrease.
Extra Help
The Medicare Extra Help program helps people with the copayments, premiums, and deductibles associated with Part D plans.
An individual may qualify for Extra Help if they have limited incomes or resources. Income limits are $30,660 for a married couple and $22,590 for a single individual. In some cases, even if a person’s income is higher than this, they may still qualify for assistance.
Resource limits are $34,360 for married people and $17,220 for individuals, and this includes:
bank accounts
mutual funds
stocks
Certain things do not count as income or resources when determining eligibility, including:
food stamps
housing assistance
primary car
primary house of residence
life insurance
Summary
Medicare Part D plans cover many, but not all, types of prescription drug. A person can check a plan provider’s formulary to make sure that their required medication is available.
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.
“”
View the original article on Medical News Today
