Medicare Part D Won't Pay For These Drugs

What Part D Covers and What It Won't

Medicare Part D prescription drug polypharmacy
Medicare Part D may not cover all of your medications. Jodi Jacobson/E+/Getty Images

Medicare Part D offered prescription drug coverage starting in 2006. Before that, Americans over 65 years old and those who were disabled had fewer options. While Medicare Part B covers some outpatient medications, it generally does not pay for many of the pills people need.

Although Medicare Part D provides more options to beneficiaries, it comes at a cost and is not all-inclusive. One of the most important decisions you make in choosing a Part D plan is finding one that covers the medications you need.

Understanding what Medicare covers and what it doesn't will help you to plan for the future.

Requirements for Medicare to Pay for Your Medications

First, the medication must be prescribed to you by a healthcare provider. Over-the-counter medications are not covered by Part D. 

Second, any medication prescribed to you by a healthcare provider needs to have a medical indication. Medicare refuses to pay for anything that is not medically necessary. If you are prescribed a drug, say for multiple sclerosis, but there is no diagnosis pertaining to this condition in your medical record, Medicare may deny coverage.

Third, any medications prescribed to you must be approved for use by the Food and Drug Administration (FDA) for use.

Fourth, any medications prescribed must be purchased within the United States. Drugs purchased from foreign countries, even if they are the same medications available in the United States, will not be covered by Part D.

Fifth, Medicare does not want to pay for things more than once. If a medication is covered by Part A or Part B, Part D will not pay.

Types of Medications Part D Plans Cover

Though Part D plans are run by private insurance companies, the federal government sets guidelines for what will be covered. There are six protected classes of medications that insurance companies are obligated to provide near complete coverage.

 

Part D plans are also required to cover at least two medications in each of the other major classes of medications.

Types of Medications Part D Does Not Cover

Medicare excludes the following medications from Part D coverage. Though some private insurance companies may opt to include some of them as a supplemental benefit, money spent on these medications will not count towards your donut hole requirement. Also, you cannot appeal to Medicare to cover an excluded drug, even if it is on the Part D formulary. You will have to look closely at individual plans before you sign up for one.

The following medications are excluded for the reasons listed but some of them could be approved for other medically approved indications. Many of these medications are not considered medically necessary in Medicare's eyes or do not have adequate data to show they have clinical benefit.

  • Barbiturates not used for treatment of epilepsy, cancer or a chronic mental health disorder
  • Cough and cold medications not used for treatment of an underlying medical condition such as allergies
  • Drugs used for cosmetic reasons not used for treatment of acne, psoriasis, rosacea or vitiligo
  • Erectile dysfunction drugs
  • Fertility drugs
  • Hair growth drugs
  • Prescription vitamins and minerals with the exception of fluoride preparations, niacin, prenatal vitamins and Vitamin D analogs for approved indications
  • Sexual dysfunction drugs
  • Weight control drugs not used for treatment of wasting from AIDS or another medical condition such as cancer

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