What Part D Plans Cover
Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost.
For example, a drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
Drug Plan Coverage Rules
Medicare drug plans may have the following coverage rules:
- Prior authorization-You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
- Quantity limits-Limits on how much medication you can get at a time.
- Step therapy-You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.
If you or your doctor believe that one of these coverage rules should be waived, you can ask for an exception.
Part D Vaccine Coverage Rules
Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness.
Find out each drug plans details for its current formulary.
Drugs You Get in Hospital Outpatient Settings Coverage Rules
In most cases, the prescription drugs you get in an outpatient setting, like an emergency department or during observation services, aren’t covered by Part B (these are sometimes called “self-administered drugs” that you would normally take on your own).
Your Medicare drug plans may cover these drugs under certain circumstances.
You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plans for a refund. Or, if you get a bill for self-administered drugs you got in a doctor’s office, call your Medicare drug plans for more information on your coverage rules.
Coverage Rules: Fill a Prescription Before You Get Your Plan Card
You should get a welcome package with your membership card within 5 weeks or sooner after the plan gets your completed application. If you need to go to the pharmacy before your membership card arrives, you can use any of the following as proof of membership:
- A letter from the drug plans that includes your membership information. You should receive this letter within 2 weeks after the plan gets your completed application.
- An enrollment confirmation number you got from the drug plan, the plan name, and phone number.
- A temporary card you may be able to print from Medicare.gov
If you don’t have any of the items listed above, your pharmacist may be able to get your drug plan’s information if you provide your Medicare number or the last 4 digits of your Social Security number. If your pharmacist can’t get your drug plan information, you may have to pay out-of-pocket for your prescriptions. If you do, save your receipts and contact your drug plans to get your money back.