What Happens If Medicare Doesn’t Cover My Medication?

According to the Kaiser Family Foundation (KFF), about 9 in 10 adults who are 65 years and older take prescription medications at this time. Most people become eligible for Medicare at age 65. With such a high number of seniors taking medications, you would assume Medicare covers prescription drugs.

Original Medicare covers inpatient (Part A) and outpatient (Part B) services. As you can see, medications do not fall under either of those categories. If you are now thinking, “What happens if Medicare doesn’t cover my medication,” keep reading!

Enroll in a Part D plan

Since Original Medicare does not cover prescription medications, you will want to enroll in a standalone Part D drug plan. Private insurance carriers sell part D plans, or you can purchase one from a Medicare broker.

If you do not have creditable coverage for Part D, you will want to enroll in a Part D plan during your Initial Enrollment Period (IEP). Your IEP begins three months before your 65th birthday month and ends three months after your birth month. If you fail to enroll in a Part D plan during that window, you will pay the total cost for your medications at the pharmacy.

How Medicare Part D works

When you are searching for a Part D plan to enroll in, you will want to find a plan with your essential medications listed on the plan’s drug formulary. A drug formulary is a list of prescriptions the plan will cover for that year. Although Medicare does not offer these plans, Medicare still requires that Part D plans provide at least two drugs in each therapeutic class. For example, every Part D plan must cover:

  • Anti-cancer medications
  • Antipsychotics
  • Antidepressants
  • HIV/AIDS drugs
  • Immunosuppressants
  • Anticonvulsants

Although Part D plans are required to cover these medications, they do not have to cover all prescription drugs on their formularies. Part D plans are not required to cover benzodiazepines, drugs for weight loss, vitamins, compound medications, or barbiturates.

It’s common for seniors to enroll in a Part D plan and realize one of their essential medications is not included on their Part D plan’s drug formulary. If you find yourself in this situation, you can change your Part D plan during the Annual Election Period.

When you can change Part D plans

Part D drug plans have lock-in periods. Once you enroll in a Part D plan, you are locked into that plan until the Annual Election Period unless you qualify for a Special Election Period mid-year. The Annual Election Period begins on October 15th and ends on December 7th every year. During that timeframe, you would be able to drop your Part D plan and enroll in a new plan that covers your medications.

When you enroll in a Part D plan, you will need to order your prescriptions from a pharmacy in your plan’s network. However, if you ever move out of your state, you will have a two-month Special Enrollment Period (SEP) to enroll in a new Part D plan in your new area.

Medication discount programs

If you find yourself in a Part D plan that doesn’t cover your medications or if you chose not to enroll in a Part D plan, you do have options! There are many drug discount programs available across the country.

Clever RX is a medication discount program that will negotiate a drug’s discount with the pharmacy so that you will save money on your medications! This program is 100% free to use. You can use this program whether you have a Part D plan or not. However, if you have a Part D plan, you cannot use both a Clever RX coupon code and your Part D plan. You would have to present one or the other. If you pay for your medications with the Clever RX coupon, the money you pay will not go towards your Part D deductible.

Final point

Finding a drug plan that covers your medications can be tedious if you are prescribed different types of medications. You don’t have to go at this process alone – you can visit Medicare.gov for help, or you can work one-on-one with an agent at a Medicare broker. If a Part D plan isn’t right for you, research the different drug discount programs to see if they offer any savings.

Post Author: Connor Robert