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Will the Medicare Formulary Cover My Drugs?

Each Medicare Prescription Drug Plan will have a list of drugs it covers, called the plan’s formulary. The formulary is important to you because it will tell you three things:

  • The names of the drugs the plan covers
  • How much you would pay for each drug
  • If there are limits or restrictions on your ability to get a drug

The formularies will include both generic and brand name drugs.

Brand vs. Generic

Each Medicare Prescription Drug Plan is required to post its formulary on its website and update it each month. You can also find information about drug lists on the Medicare.gov Plan Finder.

Some drugs are on every plan’s formulary because Medicare requires it. There are also other drugs that the Medicare law says the plans cannot cover. Medicare must review and approve each plan’s drug list.

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. The Medicare Prescription Drug Plans must have “all or substantially all” of drugs in the following six categories:

  • Anticonvulsants used to treat epilepsy and other conditions, including mental health conditions
  • Antidepressants
  • Antipsychotics
  • Anti-cancer
  • Immunosuppressant drugs
  • HIV/AIDS drugs

The plans may put these drugs on different tiers or levels and have different copays.

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.

Which drugs do all plans exclude by law?

The law says the plans do not have to cover some drugs:

  • Over-the-counter drugs that you can buy without a prescription
  • Drugs used for the symptoms of cough and colds
  • Prescription vitamins and minerals, except for prenatal vitamins and fluoride preparations
  • Barbiturates, unless used to treat epilepsy, cancer or a chronic mental disorder. These drugs are typically used for sedation or to control seizures. Example: Phenobarbital or Nembutal®
  • Drugs used for anorexia, weight loss or weight gain
  • Drugs used to promote fertility
  • Drugs to increase hair growth

Plans with enhanced alternative drug coverage

Some plans can have “enhanced alternative coverage.” This means they can cover some of these excluded drugs. They would probably charge a higher premium for this additional benefit.

Will injections or shots I get at my doctor’s office be covered?

If you get drugs in your doctor’s office now, you will still get them and pay for them in the office. This will not change. This includes shots (like allergy shots) and drugs that you get by intravenous infusion, such as chemotherapy and other immunotherapy.

If you get a shot in your doctor’s office that Medicare Part B does not cover, your Medicare Prescription Drug Plan may pay for it. You may need to pay in full at the office, and then the plan will pay you back. Contact your plan for the details.

If you get a drug at the pharmacy and take it to your doctor’s office to have them give it to you, your pharmacist will bill your drug plan for it.

What can I do if my drug is not covered on my plan’s drug list?

If you find that one of your drugs is not covered, the first thing you should do is contact your plan to ask why. Your plan should have a toll-free phone number (listed on your plan ID card) you can call to get this information.

Your plan may not cover the drug you need because the drug is not on your plan’s formulary or the plan may have special rules or set limits on how you get your drugs.

You have some options:

  • Pay full price for the drug (however, your costs for this drug will not count toward your out-of-pocket costs), OR
  • Talk with your doctor to see if you can switch to a similar drug that is on your plan’s formulary, OR
  • Ask your plan for an exception.

Your plan must make sure that you can get the drugs you need. A 30-day supply can be provided to transition you to a new drug that is covered or give you time to ask for an exception.

How do I ask for an exception?

You must call or write your plan and ask for the exception or special permission. Your doctor must also send a statement. It must say that the prescription drug you have asked for is medically necessary to treat your disease or condition. The plan would need to know what other drugs you’ve tried, how they worked and how this one is working.

How long will it take for a decision?

The plan must let you know if it will cover the drug or if it will change your copay within 72 hours. If your doctor believes that waiting 72 hours for the drug is a risk to your health, the plan must let you know in 24 hours or less.

If my plan agrees to cover my drug, do I have to ask for an exception every time I get a refill?

No, once the plan says it will cover your drug, gives you the amount you asked for or gives you a lower copay, you should get the drug under those terms for the rest of the enrollment year. You should not need to ask again for the same drug.

What if my exception is denied?

If your exception is denied, you may challenge the decision with an appeal.

The first step in an appeal is to ask your plan for a redetermination:

  • You have 60 calendar days from the date your exception was denied to ask for a redetermination.
  • Find out what your specific plan’s rules are about the appeal process, but generally you can begin by writing or calling.
  • For standard redetermination requests, your plan will give you an answer within 7 calendar days (72 hours for an expedited request).

If your plan approves your redetermination, your medication will be covered and you have to do nothing further.

There are four additional steps you may need to go through if your appeal continues to get denied:

  1. Reconsideration – if your redetermination is denied, an Independent Review Entity (IRE) reviews your request for coverage.
  2. Hearing with an Administrative Law Judge – if your reconsideration is denied, your case can be reviewed by a judge who works for the government in the U.S. Department of Health and Human Services.
  3. Review by Medicare Appeals Council – if the Administrative Law Judge rules against you in your hearing, you can receive a final review within the Medicare system.
  4. Review by the Federal Court – you can request this review if the Medicare Appeals Council rules against you. If the federal court rules against you, you may appeal the decision in a court of appeals and ultimately bring the case to the Supreme Court.

If you need to appoint someone to file for exceptions or appeals on your behalf, you can use the Appointment of Representative Form. Download the form.

What are special rules or limits for prescription drug coverage?

Plans may have special rules or may set limits on how you can get your drugs. These rules encourage you to use drugs that cost the least.

Three of the most common controls are prior authorization, quantity limits and step therapy.

What is prior authorization?

Your Medicare Prescription Drug Plan may have to approve some drugs before your doctor writes the prescription. Otherwise, the plan will not pay for it. Your doctor’s office will help you do this. The Medicare Prescription Drug Plan does this to make sure:

  • The drug is a standard medical treatment for your condition, and
  • Your doctor has considered other drugs that treat your condition effectively at a lower cost.

What are quantity limits?

The plan may let you have only a certain amount of the drug each month. This is called a quantity limit. For example, the normal dose for a certain drug is 1 pill a day – or 30 pills a month. Some people might need 2 pills per day, or 60 pills per month. The plan may limit the quantity for the month to 30 pills. Then the plan would only pay for 30 pills.

If you need more than the plan allows, you and your doctor would need to ask the plan for an exception. You would have to tell the plan why the lower amount doesn’t work for you.

What is step therapy?

These are instructions that say what drugs to use for a condition. They start with the simplest (and usually least expensive) drug to treat the problem or condition. If that drug doesn’t work, then you go to the next level and try that one. If that doesn’t work, you try the next level.

Some drug plans that use step therapy may ask you to start with an over-the-counter medication—a drug you can buy without a prescription. If you have to use an over-the-counter drug first, the plan has to give you the over-the-counter drug for free. The plan cannot charge you for it.

Next steps:

Learn About Medigap Coverage  or  Learn About Part D Costs