Drug plan coverage rules

Medicare Prescription Drug Plans may have these coverage rules

  • Prior authorization: You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it.
  • Quantity limits: Limits on how much medication you can get at a time.
  • Step therapy: You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.

If you or your prescriber believe that one of these coverage rules should be waived, you can ask your plan for an exception.

Part D vaccine coverage

Except for vaccines covered under Medicare Part B (Medical Insurance), Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

Drugs you get in hospital outpatient settings

In most cases, the prescription drugs you get in a hospital outpatient setting, like an emergency department or during observation services, aren't covered by Part B (these are sometimes called "self-administered drugs" that you would normally take on your own). Your Medicare drug plan may cover these drugs under certain circumstances.

You'll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Or, if you get a bill for self-administered drugs you got in a doctor's office, call your Medicare drug plan for more information.