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Excluded Drugs from Medicare Drug Plans

Medicare Prescription Drug Formularies

A formulary is a list of covered prescription drugs under a specific Medicare Part D Plan. The Centers for Medicare and Medicaid Services (CMS) require all prescription drug plans to:

  • Include at least (2) drug chemically distinct options in 148 drug categories (in other words, a Part D plan could not have a brand name drug and its generic equivalent as the two drugs since they are chemically identical)
  • Essentially include all drugs in the following six drug categories
    • Immunosuppressants
    • Antidepressants
    • Antipsychotics
    • Anticonvulsants
    • Antiretrovirals
    • Antineoplastics

What Drugs are Typically Excluded from Medicare Part D Plans?

Although there are certain requirements as prescribed by the CMS, the following types of common drug classes are typically excluded from Medicare Prescription drug plans (in certain cases, the drug will be covered if the drug is used to treat symptoms related to a specific disease):

  • Over-the-counter (OTC) medications (e.g. Aspirin, Benadryl)
  • Vitamins and minerals
  • Fertility Drugs
  • Erectile dysfunction (e.g. Viagra)
  • Hair loss drugs (e.g. Rogaine)
  • Insulin
  • Drugs to Quit Smoking (e.g. Chantix, Nicotine Patches)

The above Medicare excluded drug list is not exhaustive so if you are unsure of whether your prescription drugs are covered, you should contact your Medicare insurance plan provider or the CMS.

Medicare Part D Exclusions in 2014

Drug plans are not standardized with respect to the number of drugs available. In a recent study conducted by Healthpocket, data showed that there are vast differences of covered drugs in 2014 Medicare Drug Plan formularies (ranging from 995 to 2333 covered drugs for Medicare Part D Plans). Even if a drug is included in a prescription drug plan’s formulary, there are often restrictions (quantity limits, prior authorization or step therapy).

As part of Medicare’s annual enrollment period, eligible consumers should confirm if their drug plan covers all of the drugs for the upcoming plan year and if there are any unreasonable restrictions in obtaining their prescriptions.

How We Can Help

HealthPocket can help you by showing you all your choices for Medicare Part D plans and Medicare Advantage plans with prescription drug coverage. Our website allows you to provide information that will help personalize the cost for each plan. When you’ve selected the right Medicare plan, we will give you information so you can contact any carrier so you can fully understand the coverage and to make your purchase.

Sources:

http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/downloads/Chapter6.pdf
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/downloads/PartDDrugsPartDExcludedDrugs.pdf

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