There are certain kinds of drugs that are excluded from Medicare coverage by law. Medicare does not cover:
- Drugs used to treat anorexia, weight loss, or weight gain
- Note: Part D 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 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.
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.
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.