How Medicare Drug Coverage Works
Original Medicare does not include any drug coverage. Join a Part D Drug Plan from a private insurance carrier to ensure you have the coverage you need.
The Centers for Medicare and Medicaid Services (CMS) states that in 2019 the coverages offered by a Part D Plan must be equal to or better than the following.
- Initial Deductible – Equal to or less than $415.
- Initial Coverage Limit – You pay a copayment or coinsurance up 25% of the retail cost of your prescriptions/drugs until your retail drug costs reach $3,820.
- Coverage Gap – Once you reach the coverage gap you will pay a maximum of 25% of the retail cost of your brand name drugs and a maximum of 37% the retail cost of your generics until the amount you have paid out of your pocket for the year reaches $5,100.
- Catastrophic Phase – Once you have spent $5,100 out of your pocket for your drugs you will enter the catastrophic phase of your coverage. In this period, the retail cost of your generics (the greater amount of $3.40 or 5%) and the retail cost of your brand drugs (the greater of $8.50 or 5%) will be your responsibility.
These coverage periods are for the calendar year and do not reset, even if you change plans before the next calendar year. Some plans do offer more coverage through the coverage gap (donut hole); check with a licensed insurance agent that specializes in Medicare to learn which plan is best for you.
How Do I Know What Drugs Are Covered Under the Plans
All Part D Plans have a formulary or lists of drugs that they cover.
Covered Drugs must be:
- Approved by the FDA
- Sold and used in the USA
- Be for an accepted medical condition
- Only be available through a prescription
Part D won’t cover drugs covered under Original Medicare.
Medicare Part D Drug Plans must cover a minimum of two drugs in each therapeutic class, and certain vaccines, such as the Shingles vaccine and diabetic supplies. It is a requirement from Medicare that they must cover all drugs in the six classes listed below.
- HIV/AIDS drugs
- Cancer Drugs
What Are Drug Tiers
The drugs are classified by different tiers in a prescription drug plan. The tier determines your different cost sharing (copay or coinsurance), the amount you will be responsible to pay. Tier 1 drugs will be the cheapest and tier 5 will be the most expensive.
If your doctor prescribes you a medication that is a higher tier, you may be able to save money if he/she can recommend and prescribe a lower tier medication.
- Preferred/common generic drugs
- Non-preferred, more expensive generic drugs
- Preferred brand name drugs
- Non-preferred brand name drugs
- Specialty drugs
Other Terms and Rules You Need to Know
Nearly all Medicare Part D Plans use rules for the covered drugs, known as coverage rules. These rules place certain limits on coverage for certain drugs. These rules promote the proper use of medications that are medically necessary and help to keep the plan costs under control.
This rule requires you to try similar, lower cost prescriptions that have been proven effective for people with the same condition before you can “Step Up” to the higher cost prescription.
If your doctor thinks your condition requires the higher cost medications, or if you have already tried the lower cost alternative, then your doctor can contact your plan and ask for an exception to the step therapy rule.
The plans can limit the quantity or number of drugs/pills they will cover for you during an allotted amount of time. They can do this for both safety and cost reasons.
For example, they can limit your pain medication to a 30-day supply instead of a 90-day supply. If you need more than the limit, your doctor will have to contact your plan to provide more information about the medical condition.
If the plan has this as a condition for a medication you’re taking you’ll be required to have your doctor contact the plan before you can fill your prescription.
The doctor will have to show the medically necessary reason why you must take that specific prescription for it to be covered under the plan.
What If My Drug Is Not Covered Under My Plan
If your drug isn’t covered under the plan formulary, don’t worry. You can either ask your doctor to switch you to a different medication that is covered or ask for an exception.
- Tier Exception – A tier exception is when you get a higher tier drug at a lower tier cost. This tier exception could be granted because the lower cost drug, will not be as effective in treating your condition.
- Formulary Exception – A formulary exception is when your doctor believes a prescription is necessary but is not on the plan formulary. Or if your doctor believes that a rule should be waived, such as step therapy or quantity limit.
Coverage for Advair is available for 93% of Medicare Part D and Advantage Plan beneficiaries if:
- You’ve spent a minimum of $600 on prescription drugs through your Part D plan during one calendar year.
- You must reside in one of the 50 U.S. states, the District of Columbia or Puerto Rico.
- Total household monthly income is equivalent to or less than the required amounts in the GSK Income Guideline.
Medicare typically doesn’t cover the costs of medications like Androgel.
- There’s a program called the “Abbvie Patient Assistance Foundation” that provides Abbvie medicines (such as Androgel) with zero costs to those who suffer from financial difficulties.
- Applicants are looked at on a case-by-case basis; typically, those eligible don’t have healthcare coverage nor any alternative sources of coverage for funding for this drug.
Albuterol is a drug (on the more expensive end) that is often used to treat and prevent bronchospasm.
- Albuterol has brand-name versions as well as generic brands; however, the two are not interchangeable.
- Generic Albuterol is typically covered by the majority of Medicare plans.
In prior years, many Medicare Part D carriers covered Ambien under their plan; but as of lately only a few Medicare
- Advantage plans and only one prescription drug plan (Part D) will cover the costs of this drug.
- Due to the lower cost alternative, Medicare plan providers are more likely to cover the generic equivalent to Ambien (Zolpidem Tartrate).
89% of Medicare Part D and Medicare Advantage plans cover the cost of Adderall.
- Certain Medicare plans have restrictions on coverage of Adderall.
- Although Medicare Part D plans generally cover the cost of Adderall, most plans put a restriction on the amount of this
- the prescription that can be acquired at a single time.
Yes, 69% of Medicare Part D and Medicare Advantage plans will cover the cost of this drug.
- Avonex is considered a Tier 5 drug; drugs in these tiers often cost more than those of the tiers below them (1-4).
- Medicare plans may have restrictions on coverage for this drug that might include quantity limits and prior authorization.
100% of Medicare Part D and Medicare Advantage plans cover the costs of this drug.
- Medicare plans may have certain restrictions on coverage of this drug like quantity limits.
- Ativan is a Tier 1 drug, which is generally inexpensive (meaning your co-pay will be low).
Only 40% of Medicare Part D and Medicare Advantage plans cover this drug, it’s basically a coin toss.
- If your Medicare Part D plan does cover this drug, most plans will require prior authorization before providing coverage for this drug.
- Actemra is a Tier 5 drug.
94% of plans will cover the cost of Alprazolam.
- This drug is considered a Tier 1 drug and has restrictions on coverage such as quantity limits.
Medicare Part D does not cover costs of Avenova.
- Avenova is part of the Medical Supplies and Devices class which is covered under a different Medicare Plan other than Medicare Part D.
About 60% of Part D and Advantage plans will cover this medication.
98% of Medicare plans cover the costs of this drug.
- Eliquis is a Tier 3 drug and has coverage restrictions such as quantity limits.
98% of Medicare Part D plans to cover costs of Gleevec.
- Coverage restrictions include quantity limits and prior authorization.
- Gleevec is a Tier 5 drug, making the cost higher than those on other tiers.
Yes, 99% of Medicare Part D and Medicare Advantage Plans cover Humira.
- Cost of coverage will vary between plans; coverage restrictions include quantity limits and prior authorization.
- Humira a Tier 5 drug.
Generally, no, Medicare Part D plans won’t cover this drug and it’s likely to be quite expensive.
- Cost of this drug will depend on what stage of coverage you’re enrolled in.
- The general range of co-pay will run you roughly $15,429 for Harvoni.
Yes, 100% of Medicare Part D and Medicare Advantage plans cover this drug.
- Co-payments will be determined on the coverage stage you’re enrolled in; co-pay ranges can be anywhere from $3,719 to as much as $14,875.
- Some Medicare plans have restrictions on coverage for this drug such as, quantity limits and prior authorization that must be met before Medicare coverage can begin.
- Imbruvica is a Tier 5 drug
Yes, 100% Medicare Part D and Medicare Advantage plans cover the cost of Ibrance.
- Coverage restrictions for Ibrance include prior authorization and quantity limits.
- Typically, Ibrance is in Tier 5 of the Medicare Part D drug formulary.
85% of Medicare Part D and Advantage plans cover the cost, depending on your plan – the cost of Invokana may be covered.
- Co-payments vary between plans and range anywhere from as low as $18 up to $568; coverage restrictions for Invokana are generally quantity limits.
- This drug is a Tier 3 prescription.
100% of Medicare Part D plans will cover the costs of Ibrutinib.
- Medicare will pay the majority of your drug costs once you meet your deductible
- Prior authorization and quantity limits are some restrictions on coverage that Medicare Part D may require before covering costs of this drug.
- Ibrutinib is a Tier 5 drug.
For patients with diagnosis’ aside from PIDD like:
- chronic inflammatory demyelinating polyneuropathy (CIPD)
- Guillain-Barre syndrome
- Idiopathic thrombocytopenic purpura (ITP)
- Myasthenia gravis
- or other disorders that Medicare normally covers when administered in an outpatient setting or doctors’ office
- Medicare Part D should cover costs of IVIG in a home care setting
Depending on your plan determines the amount of coverage you have under your Part D plan.
- Part B will cover many diabetes prescription needs.
- Medicare Part D covers the drug administered
- The actual pump is covered by Medicare Part B.
83% of Medicare Part D and Medicare Advantage plans cover the costs of Trulicity; co-payments for the drug will depend on the stage of coverage you have.
- Medicare has coverage restrictions for this drug such as quantity limits.
- Trulicity is a Tier 3 on the Medicare drug formulary.
97% of plans will cover the costs of Restasis.
- Quantity limits are a coverage restriction for this drug.
- Restasis is a Tier 3 drug, according to Medicare.
Only 76% of Part D/Advantage Plans will cover costs of Repatha.
- Coverage restrictions for Repatha are prior authorization and quantity limits.
- This drug is a Tier 5 – non-preferred brand-name drug.
All Medicare Part D and Medicare Advantage Plans will cover the cost of Revlimid.
- Coverage restrictions include prior authorization and quantity limits.
- Revlimid is a Tier 5 prescription.
The majority (95%) of Medicare Part D and Advantage Plans cover this drug.
- The stage of coverage you have will determine your copayment
- Restrictions on coverage include quantity limits.
- Victoza is commonly listed as a Tier 3 drug.
Generally, no, Medicare Part D doesn’t cover the costs of this drug.
- This drug can be quite expensive when paying out-of-pocket.
No, Medicare Part D will not cover Vancomycin; this drug can also be quite expensive without healthcare coverage.
Yes, 100% of Medicare Part D plans cover Valium.
- Your specific plan and its coverage will determine your copayment amount.
- Coverage restrictions are quantity limits as well as prior authorization.
79% of Part D plans will cover this drug.
- The coverage stage you’re in will determine the amount you pay.
- Although Vagifem has no prior restrictions, it typically falls under the Tier 2 drug list.
Medicare Part D covers Xarelta; however, coverage and costs vary between Medicare Part D plans.
- Out-of-pocket costs like deductibles, copayments, and coinsurance for Part A and Part B services may still be your responsibility even if you have Medicare Part D drug coverage.
90% of Medicare Part D plans cover Xifaxan.
- Coverage restrictions for this drug include prior authorization and quantity limits.
- Xifaxan is a Tier 5 drug.
Generally, no Medicare Part D will not cover Xeloda.
- The payment cost of this drug will depend on other healthcare coverage, or coupons you find that may apply to the cost of Xeloda.
For the most part, yes. Most Medicare Plans cover Xanax.
- Coverage restrictions are the limits on the quantity of the drug in an allotted time frame.
Coverage of Xiidra will depend on details of your specific drug coverage plan; only 31% of Medicare Part D and Advantage Plans cover Xiidra.
- Xiidra is a Tier 4 drug, and coverage restrictions will include quantity limits as well as prior authorization.
For the most part, yes. 74% of Part D and Advantage plans will cover this drug.
- Xelijanz is a Tier 5 drug, restrictions on coverage include both prior authorization and quantity limits.
Yes, Medicare Part D will cover Xtandi.
- The amount of coverage will vary from plan to plan.
Although Medicare Part D covers Xarelto, the costs will vary within plans.
- You may still be responsible for out-of-pocket costs like deductibles, copayments or coinsurance for your Medicare Parts A and B services.
Generally, Medicare Part D will not cover Zytiga.
- The cost of this drug can be quite expensive, ask your doctor about different options for this drug.
This is an alternative to Ambien, and yes, Medicare Part D (96% of) plans will cover the cost of this drug.
- Like Ambien, Medicare Plans have some restrictions on coverage for this drug such as quantity limits and prior authorization.
- Zolpidem is a Tier 2 drug.
To compare drug plans in your area and see what medications those plans cover, check out the Part D plan finder tool. We can walk you through the application process and answer any questions. Give us a call, or compare rates for Medicare Supplement plans using our comparison tool here.