There are some drugs that are excluded from Medicare coverage by law. These include drugs for anorexia, weight loss or weight gain; fertility; cosmetic purposes or hair growth; relief of the symptoms of colds; prescription vitamins and minerals (except prenatal vitamins and fluoride preparations); over-the-counter drugs; and anti-anxiety and anti-seizure drugs that are in the benzodiazepine and barbiturate drug classes. (Benzodiazepine and barbiturate drugs will be covered for beneficiaries who have epilepsy, cancer or a chronic mental health disorder.) Some plans may offer enhanced coverage that includes these excluded drugs. If you have full Medicaid coverage, your state may also cover them. However, the amounts you pay for these drugs will not count toward meeting any of your Part D out-of-pocket cost limits. Many drugs covered by Medicare Part A or Part B are not covered by Part D. Drugs not covered include some oral cancer drugs, immunosuppressants, antivirals, antigens and anti-emetics. This exclusion applies whether or not you are actually enrolled in either Part A or Part B. The cost of these drugs is not counted toward your out-of-pocket limits under Part D.
Some examples of payments that DO count toward your out-of-pocket limits are:
Payments you make yourself, or that are made on your behalf by family or friends as long as you are not reimbursed by an insurer. These include your deductible, copayments and what you spend out of pocket when you are in the donut hole.
- 100 percent of the cost of brand-name drugs when you are in the donut hole. While most beneficiaries will only have to pay 25 percent of this cost out-of-pocket, the complete amount will be applied toward getting out of the coverage gap.
- Payments made by a qualified State Pharmacy Assistance Program (SPAP), but only to the extent the money is used to purchase drugs covered by your plan. Some SPAPs may encourage you to join a particular plan when you seek assistance.
- Payments made by AIDS Drug Assistance Programs (ADAPs). This was added by the health care reform law, the Affordable Care Act.