Which drugs must all plans cover?

Medicare wants to be sure that people are able to get their drugs, especially if stopping or changing drugs could cause health problems. Drugs in six categories get special attention.

  1. Anticonvulsants used to treat epilepsy and other conditions, including mental health conditions.
  2. Antidepressants
  3. Antipsychotics
  4. Anti-cancer
  5. Immunosuppressant drugs
  6. HIV/AIDS drugs

Drugs to be included in formularies:

The Medicare Prescription Drug Plans must have “all or substantially all” of these drugs on their drug lists.

The plans may put these drugs on different tiers or levels and have different co-pays.

Special rules for HIV/AIDS drugs:

Plans cannot use prior authorization and step therapy with HIV/AIDS drugs. This means you do not have to have the plan approve your drug before you buy it, and you can use the drug your doctor gives you—you do not have to try another drug first.

Medicare has made these specific statements:

  • Iressa and Fosphenytoin – They do not have to be included in the plan’s drug list.
  • Fuzeon – Plans can ask new users to get prior authorization, which means the plans must approve their drug before they buy it.
  • A plan’s drug list must have either escitalopram or citalopram.

NEXT: Which drugs do all plans exclude by law?

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