Medicare Part D, the prescription drug benefit, is the part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , or as a set of benefits included with your Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan.
Unless you have creditable drug coverage and will have a Special Enrollment Period, you should enroll in Part D when you first get Medicare. If you delay enrollment, you may face gaps in coverage Gaps in coverage are services or costs that are not covered by Original Medicare, such as vision, dental, and hearing care, as well as deductibles and coinsurance. and enrollment penalties.
Part D coverage
Each Part D plan has a list of covered drugs, called its formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. . If your drug is not on the formulary, you may have to request an exception, pay out of pocket, or file an appeal.
A drug category is a group of drugs that treat the same symptoms or have similar effects on the body. All Part D plans must include at least two drugs from most categories and must cover all drugs available in the following categories:
- HIV/AIDS treatments
- Antidepressants
- Antipsychotic medications
- Anticonvulsive treatments for seizure disorders
- Immunosuppressant drugs
- Anticancer drugs (unless covered by Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. )
Part D plans must also cover most vaccines, except for vaccines covered by Part B.
Some drugs are explicitly excluded from Medicare coverage by law, including drugs used to treat weight loss or gain, and over-the-counter drugs.
Note: For certain drugs or under specific circumstances, your drugs may be covered by Part A or Part B.