A Medicare formulary is a list of brand-name and generic drugs covered by a Medicare Part D prescription plan. It’s important to know that no Part D plan covers all drugs and that the Centers for Medicare & Medicaid Services (CMS) doesn’t have a national Medicare formulary.
Each Part D plan creates its own formulary, so two separate plans from the same private insurer may have different lists of covered drugs. The varying formularies may be part of the reason that two plans from the same company have different premiums.
Medicare sets rules for all Part D plan formularies, and federal law requires that all Medicare Part D plans include at least two drugs in each class of medications. This means it must cover two similar drugs treating the same medical condition.
All Part D plan formularies also must contain virtually all drugs in the following six categories:
- Anticancer drugs, except when covered through Part B
- Anticonvulsive treatments for seizure disorders
- Antipsychotic medications
- Antiretrovirals for HIV/AIDs
- Immunosuppressant drugs for transplants
What drugs doesn’t Medicare Part D cover?
By law, certain drugs are excluded from Medicare Part D coverage. These include drugs to treat:
- Anorexia, weight loss or weight gain
- Cold or cough symptoms
- Erectile dysfunction
Prescriptions for cosmetic purposes, such as promoting eyelash or hair growth, reducing fine lines and wrinkles, and lightening dark spots and scars, also won’t be part of any formulary.
If drugs used for the above conditions are prescribed to treat other illnesses, Medicare does allow for exceptions. Medicare Part D also won’t cover over-the-counter drugs or prescription vitamins, but it will cover fluoride and prenatal vitamin prescriptions. (A small number of women who qualify for Medicare because of disabilities are of childbearing age.)
In addition, Part D covers drugs used to treat physical wasting from AIDS, cancer or other diseases, as well as drugs used to treat skin disorders like acne, psoriasis, rosacea or vitiligo.