Does Medicare Cover Prescription Drugs?

Does Medicare Cover Prescription Drugs? Prescription drugs are an important part of our health. We understand that it can be unclear which part of Medicare covers prescriptions or how to sign up for Medicare prescription drug coverage. But we’re here to help you figure it out.

Let’s start at the beginning. Original Medicare (Parts A and B) does not cover prescription drugs. Medicare Part D is an option from private companies that Medicare recipients can enroll in to get their prescriptions covered. Additionally, many Medicare Advantage (Medicare Part C) plans provided by private companies include prescription coverage.

How Do You Know if Your Plan Covers Your Prescriptions

Each Medicare Part D plan and Medicare Advantage plan with prescription coverage comes with a formulary. It’s a complete list of all medications your plan covers.

The formulary may also include information about the different tiers of medication, pricing, deductibles, and copays. Talk with your primary care physician about your best options within your prescription coverage.

Also, check the prescription drugs covered by your Medicare Part D plan or Medicare Advantage plan before enrolling. That way, you can be sure that your prescription coverage includes medication you already take.

What If My Plan Doesn’t Cover My Prescription?

If you check your Medicare Part D plan’s formulary and it doesn’t cover a prescription, you have a couple of options. You can find an alternative prescription with the help of your doctor.

If there isn’t an alternative, you can file a formulary exception waiver. You or your doctor can file exception waivers with supporting statement documentation. If accepted, your plan will start coverage.

You could also file a tiering exception if your plan offers a medication on your formulary at a different price. A tiering exception may also allow you to receive preferred pricing instead of non-preferred.

Medication Coverage While Hospitalized

Medicare’s inpatient care benefit will cover prescription drugs for medication given while in a hospital or skilled nursing facility. Regardless of your Part D plan, Medicare Part A will cover these prescriptions.

There’s only one exception—if a medical professional outside of the facility’s staff administers the medication. In that case, Medicare Part B coverage may apply.

Medication Administered in a Clinical Setting

If you receive injections in a clinical setting, like a doctor’s office or lab, Medicare Part B will cover these medications. Your Medicare Part D plan will not be billed, and it won’t affect your formulary.

Non-Prescription Medications

Many Medicare recipients use over-the-counter (OTC) medications, like ibuprofen. Original Medicare does not cover OTC items. Medicare Advantage plans often include OTC allowances or benefits to help with costs. Check with your plan provider to see if your plan includes OTC benefits.

Let us know how we can help you by calling (833) 319-0475 or TTY 711. If you need help finding a plan that includes prescription coverage, we’d love to support you.