Posted on July 12, 2022 by Austin Lang
Posted on July 12, 2022 by Austin Lang
Everyone needs medication at some point in their lives, but it can be a pain to find out the drugs you need aren’t covered by your insurance. This is especially annoying if you’ve paid extra for Medicare prescription coverage. The plan is named “Medicare Part D: Prescription Drug Coverage”, so why isn’t it covering your prescription drugs?
While this sort of problem is thankfully uncommon, it can still be a frustrating experience. To understand why it happens, however, we need to look at how Medicare drug plans work.
Medicare Part D, like all prescription drug plans, has what is called a formulary. This is a list of approved drugs the plan will pay for and includes a selection of the most commonly prescribed medications.
Typically, a plan will prioritize generic or less expensive drugs over their more specific counterparts unless specifically prescribed. Even then, many plans prefer using a “step-therapy” approach to determine the most cost-effective treatment for your condition. You can read more about how this works in our guide to Medicare Part D.
A lot goes into determining what makes it onto the formulary, but one rule trumps all others: all drugs must be medically necessary. This means the drug must be used to treat some sort of medical condition. This rules out some common types of medication which might surprise you. Here are seven medications that Medicare Part D simply will not cover.
Weight is intrinsically linked to our health. Being under or overweight can lead to serious complications, and weight is often the first thing a doctor mentions during your yearly check-up. Naturally, there are medications that can help with weight control, like appetite suppressants and anabolic steroids. However, these drugs are not typically covered under Medicare. Your physician will prioritize exercise, dieting, and other lifestyle changes over any sort of medication in most cases. While medications can help when taken as directed, you’ll need to pay for them out of pocket in most cases.
An exception to this rule exists for patients suffering from a wasting disease, like cancer or AIDS. Drugs to slow or reverse muscular atrophy from these conditions are covered under Part D, as they are considered medically necessary. However, this exception exists only for serious conditions, and there is no equivalent exception for weight loss drugs.
In rare cases, Medicare can cover people of all ages, including those of child-bearing age. As such, it’s not uncommon for women on Medicare to seek medical assistance when looking to become pregnant. Unfortunately, fertility medications are not covered under Medicare Part D. Medicare will cover various tests to diagnose infertility, including hormone tests, sperm analysis, and CT scans, and may cover medically necessary fertility treatments. However, drugs like Clomid are simply not covered.
Medication-induced abortion is also not covered by Medicare Part D, with two exceptions:
The Hyde Amendment of 1977 prevents any federal body from funding abortion treatments except in the above circumstances, which includes Medicare. Those seeking treatment will unfortunately need to look elsewhere.
You’ve probably seen advertisements for hair restoration products. Many companies even offer prescriptions with just a short virtual doctor’s visit. Unfortunately, Medicare won’t cover drugs for restoring lost hair, nor will they cover treatments for removing wrinkles, altering skin tone, or other cosmetic purposes.
Exceptions do exist, however. Many cosmetic drugs were originally developed to treat medical conditions. For instance, minoxidil, the active ingredient in most hair restoration creams, is actually a blood pressure medication. Hair growth was discovered as a side effect and quickly became the drug’s primary use. While minoxidil is rarely prescribed for blood pressure today, a similar path of development exists for other cosmetic drugs. If a drug is being prescribed to treat a condition and exists on your plan’s formulary, it may be covered under Part D.
It should also be noted that drugs for the treatment of acne, psoriasis, vitiligo, or rosacea are considered medically necessary, and thus covered by Medicare.
Speaking of drugs originally meant for treating blood pressure, ED drugs have taken off as a major market, and with good reason: many seniors remain sexually active for their entire lives, and experience health benefits and confidence boosts from doing so. However, the health benefits of sex aren’t great enough to make ED drugs medically necessary, though they may be covered if prescribed to treat a different condition.
Now, you might be thinking: “Wait a second, a cold is a medical condition!”, which is true. However, we’re not talking about antiviral medications like Paxlovid, or bronchodilators used for asthma attacks. We’re talking about medications that treat the symptoms of a cough or cold, like antihistamines, decongestants, expectorants, and nasal steroids. These drugs can make recovering from a cold a bit easier, but they’re not actually treating the condition.
Before you reach for that bottle of Ibuprofen, you should also be aware that over-the-counter medications, in general, are not covered under Medicare Part D. However, they may be covered under certain Medicare Advantage plans.
Did you know that certain vitamins and minerals are offered via prescription? That might seem silly, but prescription supplements are placed under higher scrutiny than your typical Flintstones vitamin. For instance, most OTC vitamins use synthetic forms of nutrients, which certain people may be unable to process properly.
Prescription supplements use more bioavailable forms of nutrients, often in higher dosages. These are great if you can afford them, but unless you’re treating a specific vitamin deficiency, they’re not covered under Medicare.
Even if Medicare Part D doesn’t cover these medications, that does not mean you can’t get help.
First, if a drug is not covered by your plan’s formulary but is needed to treat a medical condition, you can request a formulary exception. This is a complicated process and is far more likely to be successful if you can prove the drug is medically necessary. For some of the drugs on this list, that’s a tall order.
For other drugs, certain Medicare Advantage plans may cover them. Coverage for OTC medications is a common benefit under such plans, and coverage for other medications may be offered at the provider’s discretion.
If you’re looking for a Medicare Advantage plan, our licensed insurance agents can help you sort through your options. Call us today at (800) 950-0608 or enter your zip code to begin your search
Austin is dedicated to breaking down complex topics, like Medicare, in a way that's easy to understand. He graduated with an M.A. from Florida Atlantic University in 2018.