Is Your Medication Covered Under Medicare?

You might assume that if a medication was covered by your employer plan, retiree plan, or other insurance, it will be covered the same way once you enroll in Medicare. Unfortunately, that is not always the case.  Some medications may still be covered the same.  Some might have a different cost, depending on the plan.  Others may be covered under a different part of Medicare than you expect.  Some medications may not be covered by Medicare at all. That is why it is so important to review your medications before choosing a Medicare plan.

What Is a Drug Formulary?

A drug formulary is the list of medications covered by a Medicare drug plan.  Every Medicare Part D plan, whether it’s a stand-alone or in a Medicare Advantage plan, has its own formulary. One plan may cover your medication, while another may not.  Even if two plans cover the same drug, they may:

• Place it in different cost levels, called tiers

• Require prior authorization

• Require you to try a less expensive medication first

• Limit how much you can receive at one time

It’s not enough to only ask, “Does this plan cover my medication?”  You need to know:

• How much will it cost?

• Is there a deductible?

• Is there a preferred pharmacy?

• Are there restrictions before the medication will be covered?

Why Medicare Drug Coverage Can Be Different

Under Medicare, which part covers the medication depends on how the drug is given, where you receive it, and what the medication is used for. For example:

• Medications you pick up at the pharmacy and take yourself are usually covered under Part D 

• Medications given in a doctor's office, clinic, infusion center, given through an IV or injection or used with durable medical equipment are often covered under Part B.

Examples may include certain chemotherapy drugs, Infusion medications, Insulin used in an insulin pump, medications used with a nebulizer machine, certain transplant medications and anti-nausea medications related to chemotherapy.

Part B also covers some vaccines, including Flu shots, Pneumonia vaccines, Hepatitis B vaccines for people at higher risk and COVID-19 vaccines. Most other vaccines, such as the shingles vaccine, are usually covered under Part D.

Why the Same Medication May Be Covered Differently

Sometimes the same medication can be covered under Part B in one situation and under Part D in another.   For example:

• Insulin is usually covered under Part D when you inject it yourself.

• But insulin used in an insulin pump may be covered under Part B.

• A medication given in a doctor's office may be covered under Part B.  The very same medication may be covered under Part D if you pick it up at the pharmacy and take it yourself at home.

Some Medications May Not Be Covered At All

There are also medications that may have been covered under a corporate or employer plan but are not normally covered by Medicare.  Examples can include:

• Some weight loss medications

• Certain vitamins and supplements

• Some medications used only for cosmetic purposes

• Over-the-counter medications

Why It Matters Which Part Covers Your Medication

Part B medications are usually covered at 80% after the Part B deductible. If you have a Medicare Supplement plan, it may pay the remaining 20%, which could leave you with little or no out-of-pocket cost.  On the other hand, if the medication is covered under Part D, your cost depends on your drug plan's formulary, deductible, and copay.

Before You Enroll, Make a Medication List Including

• Your medication name (generic or name brand, not both)

• The dosage

• How often you take them

• The pharmacy you prefer to use

Then compare how each plan covers those medications. A plan that has a low monthly premium may not be the best fit if it does not cover your medications well.  A plan with a higher monthly premium may, however, lower your annual deductible and copays. Reviewing your medications before you enroll can help avoid surprises and make sure the plan you choose is a good fit for both your health needs and your budget.

Surprise Medicare Medication Costs