While the federal government designed the model for Medicare Part D plans, every plan has its own list of covered drugs. It depends on the pharmaceutical company it is associated with. This list is called a “formulary”, and may have quantity limits, pre-authorizations or step therapy associated with a drug.
Part D Prescription Drug Plan
Drugs excluded from Part D coverage
There are certain kinds of drugs that are excluded from Medicare coverage by law. Medicare does not cover: Drugs used to treat anorexia, weight loss, or weight gain Note: Part D may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases Fertility drugs Drugs used
Small Business Health Options Program (SHOP)
Insurance plans offered through the Small Business Health Options Program (SHOP) are job-based insurance plans purchased through the Marketplace. SHOP allows businesses with fewer than 50 employees and their employees to search for and buy health coverage. SHOP plans follow the same rules as other insurance based on current work.
Part D coverage in nursing homes
If you live in a nursing home or another qualified institution (not an assisted living facility or a group home) and receive long-term care, you should be aware of how your prescription drug coverage may be affected. Specifically, different rules apply as to when you can switch plans and how
Help understanding Medicare benefits and options
If you need help understanding your Medicare rights and how to exercise them, there is free information and assistance that you can access. Below are examples of places you can get help: State Health Insurance Assistance Program (SHIP) – Each state offers a SHIP, partly funded by the federal government,
Appealing the Part D late enrollment penalty
If you were without Part D or creditable drug coverage for more than 63 days while eligible for Medicare, you may face a Part D late enrollment penalty (LEP). The purpose of the LEP is to encourage Medicare beneficiaries to maintain adequate drug coverage. The penalty is 1% of the
Part D appeals
Part D appeals Introduction to Part D appeals Requesting a tiering exception The Medicare Prescription Drug Coverage and Your Rights notice Appealing the Part D late enrollment penalty
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is the notice that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medical services or items. You only receive an EOB if you have Medicare Advantage or Part D. An EOB is not the same as a
Filing a grievance
If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal, which is a request for your plan to cover
Drug coverage under hospice
Medicare’s hospice benefit should cover any prescription drugs you need for pain and symptom management related to your terminal condition. You pay a $5 copayment for outpatient pain and symptom management drugs. You pay nothing for drugs you receive as an inpatient during a short-term hospital or skilled nursing facility