According to a Medicare Advantage literacy survey, three out of every four Medicare beneficiaries find the program confusing and hard to understand.
This confusion can lead to a lack of proper coverage or a lack of understanding of what existing coverage includes for prescription medication. This goes for all parts of Medicare.
Medicare Part A, which is inpatient and hospital coverage, and Medicare Part B, which is outpatient and medical coverage, surgical services, and supplies are just the start of Medicare. There’s also Medicare Part D, which covers drugs, but the list of what’s included is not all-encompassing.
However, Medicare Part D covers a wide range of prescription drugs taken by people with Medicare. Benefits are usually applied to a brand-name prescription and a generic version if it’s available. Each plan will have a detailed list of what medications are covered, which is known as a formulary. Plans are required to give a 30-day notice for any changes involving drugs taken by Medicare enrollees, according to Medicare.gov.
What’s not covered
The primary drugs excluded from Medicare coverage are done so by law. The drug areas not covered in Medicare Part D include those used to treat eating disorders and weight loss or gain. Your coverage may include medication related to physical wasting as a symptom of AIDS, cancer, or other diseases though.
Medications connected to fertility and erectile dysfunction are also not covered, along with prescription-grade vitamins and minerals. You may, however, get coverage for fluoride preparations and prenatal vitamins.
Drugs used for cosmetic purposes or for hair growth are also not covered. However, if you’re taking these medications because of a chronic issue, you may be in the clear. Medications used to treat rosacea, psoriasis, vitiligo and acne are not considered cosmetic drugs.
Over-the-counter drugs are also not covered by Medicare unless they’re prescribed to treat something beyond their OTC purpose. For example, according to medicareinteractive.org, cold medicine prescribed to treat shortness of breath resulting from severe asthma may be covered.
Loopholes based on use
This loophole in coverage is directly connected to whether the Food and Drug Administration has approved the drug for such use. If it hasn’t, and you’re using a drug for something other than its intended purpose based on your doctor’s recommendation, you may not receive Medicare benefits. However, you could get coverage if the drugs are listed in Medicare-approved medical drug use encyclopedias called drug compendia.
Should you find yourself hitting speed bumps when it comes to drug benefits, you have the ability to ask for a formulary exception under Medicare Part D, according to Centers for Medicare & Medicaid Services. This is given if your doctor, or Medicare itself, determines the uncovered drug is medically necessary for your health. This requires a written statement from your doctor, and you usually receive a decision within 72 hours for standard requests.
If Medicare Part D makes it challenging for you to get all of your prescriptions covered, you may want to look into Medicare Advantage plans during your next open enrollment period. Also known as Medicare Part C, plans in this area cover the basics and may have extra coverage for hearing, vision and dental. Many also include a prescription drug plan and could include health and wellness programs, according to the Department of Health & Human Services.
For the most up-to-date information on Medicare plans, visit medicare.gov.
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