Drugs that are excluded from Medicare coverage

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There are some drugs that are excluded from Medicare coverage by law. These include:

  • Drugs for*:
    • Anorexia, weight loss or weight gain (except to treat physical wasting caused by AIDS, cancer or other diseases)
    • Fertility
    • Cosmetic purposes or hair growth
    • Relief of the symptoms of colds, like a cough and stuffy nose
    • Erectile dysfunction
  • Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
  • Non-prescription drugs (over-the-counter drugs)

Starting January 1, 2013, Medicare Part D will begin covering barbiturates and benzodiazepines. Benzodiazepines are covered as a treatment for all medically necessary conditions. Until January 1, 2014,  barbiturates will only be covered to treat epilepsy, certain cancers and chronic mental health conditions. However, beginning in 2014, barbiturates will be covered for all medically necessary conditions. Check to make sure the barbiturate or benzodiazepine you take is covered on your drug plan’s formulary. Even if your plan does not cover your drug, your plan should provide you with one 30-day transition fill at sometime during the first 90 days of the year.

If your doctor prescribes a non-cancer medication on the formulary for a reason other than the use approved by the U.S. Food and Drug Administration, your drug will probably not be covered unless the use is listed in one of three Medicare-approved drug compendia (medical encyclopedias of drug uses). For anti-cancer drugs, your drug plan should accept indications of drug use from additional compendia and other peer-review medical literature.

You may also receive a denial from your part D plan stating that your drug does not meet “DESI standards.” The FDA’s Drug Efficacy Study Implementation (DESI) evaluates the effectiveness of those drugs that had been previously approved on safety grounds alone. Drugs that are found to be “less than effective” by DESI evaluation are excluded from coverage by Part D.

*Note: Prescription drugs used for the above conditions will not be covered by Medicare Part D. However, they may be covered if they are being prescribed to treat other conditions. For example, prescription medications for the relief of cold symptoms may be covered by Part D if prescribed to treat something other than a cold—such as shortness of breath from severe asthma—as long as they are approved by the U.S. Food and Drug Administration (FDA) for such treatment.

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