Medicare is the federal health insurance program for individuals over the age of 65, from low-income status, or those with disabilities and end-stage renal disease that requires transplant or dialysis. Medicare provides coverage of medications and treatments that these patients would otherwise be unable to afford.
Who Is Covered by Medicare?
- Seniors (over 65)
What Does Medicare Cover?
Depending on the severity of situations and related medical variables, Medicare typically covers the following:
- Hospital inpatient care
- Skilled nursing facilities
- Home health care
What Prescription Drugs Does Medicare Cover?
Medicare covers some prescriptions, but not all. Covered drugs depend on the reason for prescription and are divided into tiers that determine their eligibility for coverage.
Prescription Drug Tiers
- Tier 1
Generic, off-brand drugs available at the lowest price possible.
- Tier 2
Preferred brand-name drugs at prices slightly higher than Tier 1 drugs.
- Tier 3
Non-preferred brand-name drugs.
- Tier 4
Unique, high-cost, specialty drugs. Tier 4 includes the highest priced drugs, and often come with a copayment on top of insurance.
Medicine Covered by Medicare Categories:
- Sold and used in the US
- Only available by prescription
- FDA approved
- Used for the medically accepted condition
- HIV/AIDS drugs
- Cancer drugs
Drugs Not Covered by Medicare
Due to strict guidelines, many prescription drugs are not eligible for coverage by Medicare. These include the following:
- Non-FDA-approved drugs or products
- Cosmetic drugs
- Drugs for hair growth
- includes Vaniqa, Propecia, Renova
- Drugs for weight loss or weight gain
- includes Xenical, phentermine HCI, Meridia)
- Drugs to promote fertility
- includes Gonal-f, Clomid, Follistim, Ovidrel
- Cough and cold symptom relief drugs
- includes Tanafed, Tessalon Perle, Phenergan with Codeine, Robitussin AC)
- Nonprescription drugs
- Sexual dysfunction drugs (Viagra, Levitra, Cialis, etc.)
- Prescription vitamins (excluding prenatal vitamins)
- includes Foltx, Nephrocaps, and Cyanocobalamin)
- Bulk chemicals
- includes U61, U6Q, U6U, U6W, U6X
- Medical supplies
- Medical devices
- Line flush
- Drugs approved by FDA as safe but not as effective (DESI drugs)
What If My Medication Is Not Covered by Medicare?
Sometimes, prescription drugs you take lose their insurance coverage based on annual reviews and changes to prescription lists.
If you are insured by Medicare, and the prescription you want or need is not or no longer covered under your plan, you have several options for getting the medical care you need:
- Pay more for prescription
If you want to stay on the medication you are used to, but its coverage has changed, you can pay the difference in cost. Sometimes, there will be a change in the cost covered; other times, you will have to pay full price out of pocket.
- Continue through the end of year
In some cases, you can fill your prescription through the end of the year at the current covered price.
- Switch to a new medication
Speak with your physician about other drugs that might be available to satisfy your medical needs.
- Switch to a different brand
A generic or different brand of the same medication might be available for Medicare coverage — ask your pharmacist or physician.
- Request an exception
If your prescription is medically necessary, you may request for a coverage eligibility exception.
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