There are certain kinds of drugs that are excluded from Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). coverage by law.
Drugs Medicare does not cover
Medicare does not cover:
- Drugs used to treat anorexia, weight loss, or weight gain
- Note:Â Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases
- Fertility drugs
- Drugs used for cosmetic purposes or hair growth
- Note: Drugs used for the treatment of psoriasis, acne, rosacea, or vitiligo are not considered cosmetic drugs and may be covered under Part D
- Drugs that are only for the relief of cold or cough symptoms
- Drugs used to treat erectile dysfunction
- Prescription A prescription is an order for a health care service or drug written by a qualified health care professional. vitamins and minerals (except prenatal vitamins and fluoride preparations)
- Non-prescription drugs (over-the-counter drugs)
Note: Prescription drugs used for the above conditions may be covered if they are being prescribed to treat other conditions. For example, a medicine 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 it is approved by the U.S. Food and Drug Administration (FDA) for such treatment.
FDA-approved uses
If your doctor prescribes a non-cancer medication on your plan’s formulary for a reason other than the use approved by the FDA, 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 fighting cancer, your drug plan will draw from these and additional compendia and peer-reviewed medical literature when deciding whether to cover a drug.
Drug effectiveness
You may also receive a denial from your Part D plan stating that your drug does not meet the FDA’s Drug Efficacy Study Implementation (DESI) standards. DESI evaluates the effectiveness 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.