Medicare part D has been into effect since 1st January 2006. It came into existence after the Medicare Prescription Drug Improvement and Modernization Act was passed. The eligibility criteria for Part D includes enrollment in a stand-alone PDP (Prescription Drug Plan) or MA-PD (Medicare Advantage Plan with Prescription Drug coverage). Medicare part D covers most of the prescription drugs, however certain medicines have been excluded from Medicare coverage. Which are these medicines and how to get medicines that are not under Medicare? The drugs listed below are not allowed to be covered under Medicare Part D by the US government. These drugs are termed as exclusions.
- Medicines that are used for hair growth or cosmetic purposes
- Drugs that are used for weight gain, weight loss or anorexia
- Non prescription drugs that are not part of a step therapy
- Drugs used to boost fertility, or in some instances, sexual dysfunction
- Drugs used for relieving the symptoms of cough or cold
- Certain outpatient medicines for which the manufacturer demands that monitoring services or associated tests be bought from the manufacturer solely as a sale condition.
- Benzodiazepines such as diazepam, temazepam (Restoril), alprazolam (Xanax), lorazepam (Ativan), clonazepam(Klonopin), etc.
- Barbiturates such as mephobarbital (Mebaral), Phenobarbital, etc.
Plans covering the excluded drugs listed above are prohibited from passing these costs onto Medicare. Also, the plans are bound to repay CMS in case they bill Medicare in such scenarios. Some beneficiaries are dual eligible (Medicare + Medicaid). Medicaid is a program run by a state providing health benefits to eligible low-earning, disabled individuals. Funding for the Medicaid is shared by both, federal and state governments. The actual coverage amount and eligibility criterion varies for different states. Medicaid may cover some of the drugs listed above, which are not covered by Medicare. The CMS (Centers for Medicare and Medicaid Services) has approved states to receive and cover federal matching funds for these drugs. Benzodiazepines and barbiturates are specifically important for the consumers that need mental health care medications. Several state Medicaid programs plan on continued coverage of these medications, hence dual eligible people residing in these states do not need to find Medicare plans that cover these drugs.
Most of the medicines categorized as benzodiazepines are available in generic form, for instance, Xanax which is sold in generic form as alprazolam. Medicaid programs prefer generic medicines since they are at par with the brand name medicines on the count of safety and effectiveness and are cheaper as well.
It should be noted that there are certain limitations that differ state wise. Medicaid programs have restrictions on several factors such as number of drugs simultaneously prescribed from the same category, number of tablets per month and maximum dosage per day. For example, Medicaid does not usually cover more than 90 pills of Xanax (alprazolam) per month, irrespective of the strength, unless a physician or pharmacy sends an override request and gets prior authorization. If 2 medicines from benzodiazepine class are being prescribed in combination, the prescribing physician needs to procure a prior authorization that explains why these 2 drugs are being recommended in combination. The chances of getting an approval are more if these 2 medicines are prescribed for treating separate disorders.
The procedure for prior authorization simply needs a form submission that states the reasons for that medicine to be prescribed. However, the guideline states that non-preferred drug be covered only if the efficiency of the preferred medicine is low.
This was about how to get medicines that are not under Medicare. I hope you found this content useful.