Why are there rules about whether and when certain drugs are covered?

There are many rules that can vary by plan. There are certain drugs that Medicare drug plans aren’t required to provide, such as benzodiazepines, barbiturates, and drugs for weight loss or gain. Some plans may choose to cover these drugs as an added benefit. In addition, drug plans aren’t allowed to cover drugs for erectile dysfunction or over-the-counter drugs for relief of colds.

Plans may also exclude certain drugs from coverage. Although your Medicare drug plan may not have a specific drug on their list of covered drugs (formulary), a drug that is safe and effective for the same purpose will be available for drugs that are covered by law. This may be in the form of a generic drug or therapeutic alternative (other brandname drug) that has the same benefit as a more expensive brand-name drug.

Plans have rules that need to be followed before certain prescriptions can be filled. For instance, some drugs may have more side effects or have restrictions on how long they can be taken. Some drugs cost more than others even though some less expensive drugs may work for you just as well.

All plans have an exceptions process. If your doctor believes you need a drug that isn’t on the plan’s list or the plan has rules that should be waived, he or she can request an exception. Not all exceptions are granted. See pages 131 – 136 for more information.

Important: Specific formulary information isn’t included in this handbook because each plan has its own formulary. Formularies can change. Contact your plan for its most current formulary.

All Medicare drug plans have negotiated to get lower prices for the drugs they cover. This means using drugs on your plan’s list will generally save you money. You will get lower prices for your prescriptions before you meet the deductible and when you are in the coverage gap (the period where you pay all of your costs). Using generic drugs can also save you money. For more information about other drugs you can use, go to www.medicare.gov on the web. Select “Compare Medicare Prescription Drug Plans.” Or, call 1 800 633 - 4227. TTY users should call 1 877 486 - 2048.