What the Medicare drug benefit covers

Question 2 of 9 (use "Last" or "Next" buttons to see more)

Each Medicare prescription drug plan has its own formulary (list of covered drugs). A Medicare private drug plan generally will only help pay for drugs that are on its formulary and that you purchase at a pharmacy in the plan’s network.

Some drugs are explicitly excluded from Medicare coverage by law, including certain anti-anxiety drugs, weight loss and gain drugs, and over-the-counter drugs. While these drugs are excluded from Medicare paying for them, plans can choose to cover them.

If the drug you need is not on your plan’s list of covered drugs, as long as the drug is not excluded from Medicare coverage by law, your doctor may be able to ask for an exception to have your plan cover it.

Drug plans provide incentives for you to use generic drugs by offering lower out-of-pocket costs for those drugs. In addition, plans can put restrictions on drugs that are on the formulary, like requiring you to get permission before a drug will be covered (prior authorization). If a drug is not on the formulary or if you buy it from a pharmacy not in the plan's network, you will have to pay the full cost yourself and that will not count towards the limit for reaching catastrophic coverage ($4,550 in 2014).

Only what you pay for drugs on your plan’s list of covered drugs will count towards your out-of-pocket costs. Once you reach a certain amount in out of pocket costs, the amount will you have to pay for your prescriptions will change.

 


 

 

 

 

 

 

 


Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

Donate Now
 
 
Go to previous question Go to next question
 
GO TO
Why is my Medicare drug plan refusing to cover a drug that is on its list of covered drugs (formulary)?

Why am I paying a different amount for my drugs this month?

Paying a different amounts for my drugs throughout the year with Extra Help

Drugs that are excluded from Medicare coverage

Help Understanding Medicare Benefits and Options

 
LINKS
The Partnership for Prescription Assistance

FDA Generics Q&A

WorstPills.org Saving Money When Buying Prescription Drugs

 
< Last | Next >