Which Prescription Drugs are Covered under the Medicare Part D plans?
The list of prescription drugs covered by the Medicare Part D plans (or a Plan's Formulary) can vary plan to plan. However, every therapeutic category of prescription drugs will be covered under the Medicare Part D prescription drug plans.
Medicare Part D plans must cover all or substantially all drugs in six categories: antidepressants,
antipsychotics, anticonvulsants, antiretrovirals (AIDS treatment), immunosuppressants
Naturally, not every plan will cover each drug and Medicare beneficiaries must therefore choose a plan that best accommodates all of their personal prescription drug needs and financial situation.
More specifically, some plans will provide coverage for generic drugs, while other plans will focus on providing a wide range of name-brand prescription drugs. As noted, plan premiums will reflect the plan's coverage.
To quickly compare where your medication falls on every plan in your state, use either our Part D Drug Finder (Formulary Search) or Browse Drugs By Letter . You will not only see the cost-sharing (co-payment/co-insurance) for this medication on each Medicare Part D plan, but also the utilization management requirements, including step therapy, prior authorization and the exact quantity limits. For example, Q:15/30Days -- quantity limit of 15 pills per 30 day period.
Please note: All Medicare Part D plans must have a process in place for members to request exceptions to the plan's
formulary if a non-covered drug is deemed medically necessary and or if they require an exception to the utilization management requirements, including quantity limits.
Many plans are using a "tiered" approach to their Prescription Drug List (also known as a Formulary). Specific drugs are in each Tier and will have a co-payment that increases with the level of Tier. Therefore, the co-pay for Tier 3 Drugs is higher than the co-pay for Tier 1 Drugs. Also, some plans reduce the amount of co-pay per Tier depending on if you purchase their Low, Middle, or Higher Premium Plan.
Lower Premium Plan
Middle Premium Plan
Higher Premium Plan
$12 / $36
$5 / $20 / $53
$0 / $20 / $55
Premium per Month
Click one of the links below to review the specific Drug Tier, Cost-Sharing, and Utilization Management Restrictions for your medication on all Medicare Part D plans:
You can also compare the cost-sharing (co-payment/co-insurance) fees for all plans in your state using our Part D Plan Finder. This free tool also shows the plan premium and other important plan features.
The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
Medicare has neither reviewed nor endorsed the information on our site.
We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information.
However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist.
For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.
Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
Limitations, copayments, and restrictions may apply.
We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area.
However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service
area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048),
24 hours a day/7 days a week or consult www.medicare.gov.
When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare.
Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits
money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible.
The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll
during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the
Beneficiaries can appoint a representative by submitting CMS Form-1696.