Ask the Advisor - Valid Drugs Excluded From Medicare Part D Coverage

Send this article to a friend.

Printer friendly version.

Ask the Advisor - Valid Drugs Excluded From Medicare Part D Coverage

Q: Recently, I came down with bronchitis. When I went to the doctor, he prescribed a prescription narcotic cough suppressant. After I had this prescription filled, I learned that my Medicare Part D insurance company would NOT cover this drug, would not count the money I spent toward my deductible, would NOT count the cost toward my annual out-of-pocket expenses, and did NOT offer any other covered medication for this illness. I later learned the probable reason for this is that medications for bronchitis are one of the nine categories specifically excluded from coverage by legislation when the Medicare Modernization Act of 2003 (MMA) was written! What position does TSCL take on exclusions of valid drugs?

A: Under the 2003 Medicare drug legislation, coverage was provided for most medically necessary drugs. Yet millions of seniors are learning which prescription medications are covered under their drug plans and which are not. Considerable attention has been devoted to the fact that Part D plans are permitted to limit the coverage of drugs through the use of formularies, “step therapy” (requiring that patients first try less expensive drugs), prior authorization, and quantity limits.

Less well known, however, is the fact that nine entire categories of drugs were excluded under Part D legislation. Medicare will not cover them under any circumstance. These excluded drugs include:

Agents when used for anorexia, weight loss, or weight gain
Agents when used to promote fertility
Agents when used for cosmetic purposes or hair growth
Agents when used for the symptomtic relief of cough and colds
Prescription vitamins and mineral products, except prenatal vitamins and flouride preparations
Nonprescription drugs
Outpatient drugs for which the manufacturer seeks to require associated tests or monitoring services be purchased exclusively from the manufacturer or its designee as a condition of sale
Barbiturates
Benzodiazepines

Some of the drugs have been the subject of controversy for years, and this no doubt led to their exclusion. Those drugs have signficant side effects that may be exacerbated in older patients, such as over-sedation causing falls and hip fractures, and addiction. In addition, when Congress considered legislation to add a prescription drug benefit, many of the major bills advanced by both Democrats and Republicans adopted some or all of the categories of drugs that are excluded under state Medicaid programs, and excluded them from coverage under Medicare.

TSCL questions some of the exclusions, however, particularly those of drugs that are currently covered under most state Medicaid programs. The blanket exclusion of “medically necessary” drugs could result in serious harm to Medicare beneficiaries who really need them. TSCL is studying the issue and believes that certain categories could be legitimately modified by the Secretary of the Department of Health and Human Services, for coverage under Part D.

Sources: “Critical Coverage: Benzodiazepines Under Medicare Part D,” The Medicare Rights Center, June 2005.

August 2006