For individuals already enrolled in Original Medicare there are additional plans and parts that can be added and customized to the participant’s particular health care and financial situation.  Medicare Part D is an option that covers prescription medications for outpatient services offered through private insurance companies. Medicare Part D drug coverage can also be added to a Medicare Advantage plan if there is no prescription coverage in the existing Advantage plan. Part D is known to be a rather complicated benefit to grasp, as there is no other plan like it.

What Variables Can Affect my Medicare Part D Drug Coverage?

Part D private insurance drug coverage options may vary depending on:

  • What state you live in.
  • Your medication costs.
  • Your budget as it relates to how much you are willing to pay for premiums and deductibles.

When it comes to the differing aspects of Medicare careful consideration should be given when comparing Medicare plans.

What is the Donut Hole in Medicare Coverage?

There is a coverage gap in Medicare prescription drug plans termed as a “donut hole” due to the fact that there is a gap or a hole in coverage during the enrollee out-of-pocket cost timeline from reaching the deductible threshold (up to $480) then entering into the Initial Coverage coinsurance/copayment through Catastrophic Coverage. The gap comes in-between the time between initial coverage and catastrophic coverage.  However, as of 2020 the donut hole closed for all drugs, meaning that when you enter you may be responsible for only 25% of the cost of your drugs. In the past, this percentage was much higher.

What Conditions and Drug Treatments Does Part D Cover?

Part D private insurance companies supply a list of drugs that are available under their plan. This list of available medications that are offered in the plan is called a formulary. The decision-making process on selecting a plan should not be taken lightly since each plan has differing costs and a different formulary of medications. The formulary list can cover everything from generic medication to brand name or high-priced specialty drugs. In a scenario where your drug is not on a plan’s formulary you can request an exception, pay out of pocket, or file an appeal.

Part D policy insurance sponsors must cover all or most of the drugs found under the 6 drug categories listed below. Each category will supply a minimum of 2 drug options that will treat the same symptom or produce a similar result on the person taking the drug:

  • Anticancer drugs (unless covered by Part B)
  • Anticonvulsive treatments for seizure disorders
  • Antidepressants
  • Antipsychotic medications
  • HIV/AIDS treatments
  • Immunosuppressant drugs

Does Medicare Part D Cover Vaccinations?

Take note that Medicare Part B has drug coverage as well.  Medicare Part B may cover any drugs that were taken while at the hospital or vaccines that could be considered a preventative service which include:

  • The annual flu shots
  • COVID-19
  • Pneumococcal vaccines

Part D coverage may cover most other vaccines that are:

  • Commercially available
  • Reasonable, and necessary to prevent illness
  • Not covered by Medicare Part B

Does Medicare Part D Cover Drugs for Diabetes Treatment?

Medicare Part D covers diabetes-controlling drugs like insulin and administration supplies including insulin pens, syringes, needles, alcohol swabs, and gauze. It doesn’t cover insulin when it is administered via an insulin pump.

What Are the Drugs Not Covered by Medicare Part D?

It is important to understand which drugs are covered, the drugs that may not be covered by Medicare Part D include the following:

  • Drugs covered in Medicare Part B.
  • Cold or Cough related medicine.
  • Cosmetic-related drugs Fertility drugs.
  • Drugs for erectile dysfunction.
  • Mineral or vitamin supplements or drugs (with exceptions to those listed in the formulary).
  • Outpatient medication.
  • Over-the-counter drugs.
  • Weight-related medication for weight gain/loss, or anorexia.