Key Takeaways

• Medicare Part D plans do not cover all prescriptions due to formulary restrictions, tiered pricing, prior authorization rules, and coverage gaps. Understanding these factors can help you navigate your options and avoid unexpected costs.

• If your medication isn’t covered, you can explore alternatives like formulary exceptions, therapeutic substitutions, patient assistance programs, or switching to a different plan during the next enrollment period.

Why Medicare Part D Might Not Cover Your Prescription

Medicare Part D helps reduce prescription drug costs, but it doesn’t cover every medication. If you’ve ever been caught off guard at the pharmacy, it’s likely due to one of these reasons. Understanding why your prescription isn’t covered can help you take action to find a solution.

1. Your Medication Isn’t on the Plan’s Formulary

Every Medicare Part D plan has a formulary, a list of drugs it covers. Since formularies differ by plan, a medication covered by one plan may not be covered by another. Additionally, formularies are reviewed and updated each year, meaning a drug you relied on last year may no longer be covered.

What You Can Do:

• Ask your doctor about covered alternatives that may work just as well.

• Request a formulary exception if your doctor believes your medication is necessary.

• Explore switching to a different Medicare Part D plan during the next Medicare Open Enrollment Period (October to December) to ensure your medications are covered.

2. Your Drug is in a Higher Tier

Medicare Part D plans categorize drugs into tiers to determine cost-sharing levels. Lower-tier drugs, usually generics, have lower copays, while higher-tier medications—often brand-name or specialty drugs—come with higher out-of-pocket costs.

What You Can Do:

• Check if there is a lower-tier equivalent that offers the same benefits at a reduced cost.

• Request a tiering exception if your doctor can justify why a lower-tier alternative isn’t a viable option.

• Compare other Part D plans to see if a different plan categorizes your medication in a more affordable tier.

3. Prior Authorization, Step Therapy, or Quantity Limits Apply

Some medications require prior authorization, meaning your doctor must obtain approval from your plan before it will be covered. Others may require step therapy, where you must try a lower-cost drug first. There may also be quantity limits, restricting the amount of medication you can receive at one time.

What You Can Do:

• Work with your doctor to submit the required documentation for approval.

• If your medication is denied, consider filing an appeal to contest the decision.

• Explore medications that don’t have these restrictions to ensure smoother access to treatment.

4. The Medication is Excluded from Medicare Coverage

Certain drug categories are excluded from Medicare Part D coverage, including:

• Over-the-counter medications

• Drugs for weight loss, weight gain, or cosmetic purposes (like hair growth treatments)

• Fertility medications

• Non-prescription vitamins and minerals

• Medications covered under Medicare Part A or Part B

What You Can Do:

• Ask your doctor about alternative covered medications.

• Look into supplemental drug coverage that may help cover excluded prescriptions.

• Check if state pharmaceutical assistance programs offer help with excluded medications.

5. You’re in the Part D Coverage Gap (Donut Hole)

In 2025, Medicare Part D has a $2,000 out-of-pocket cap, ensuring that once you hit this amount, your plan covers 100% of drug costs. However, before reaching this cap, you may enter a temporary coverage gap (donut hole) where out-of-pocket expenses increase.

What You Can Do:

• Utilize discount programs or manufacturer coupons to reduce costs.

• Ask about generic alternatives that may be cheaper.

• If you face high medication expenses, check whether you qualify for Medicare’s Extra Help program to lower your costs.

What Are Your Options If Your Medication Isn’t Covered?

If your Medicare Part D plan doesn’t cover your medication, don’t panic—there are several ways to manage the situation.

1. Discuss Alternatives with Your Doctor

Your doctor may be able to prescribe a covered alternative that works just as effectively as your current medication.

2. Request a Formulary or Tiering Exception

If an alternative isn’t viable, your doctor can submit a formulary exception request to your Medicare plan. You can also request a tiering exception to lower out-of-pocket costs for higher-tier medications.

3. Compare Plans and Switch If Necessary

Medicare allows you to switch Part D plans during Annual Enrollment (October to December) or a Special Enrollment Period if you qualify due to a major life event.

4. Seek Assistance Programs

Pharmaceutical companies and non-profit organizations offer patient assistance programs to help individuals afford expensive medications.

5. Apply for Medicare Extra Help

The Extra Help program provides financial assistance for Part D premiums, deductibles, and copays if you meet income and resource limits.

How to Stay Ahead of Coverage Changes

Medicare Part D coverage changes every year, and what is covered now may not be covered in the future. To avoid unexpected costs:

• Review your plan’s Annual Notice of Change (ANOC) to stay informed.

• Use the Medicare Plan Finder tool to compare your current plan with other available options.

• Confirm with your doctor and pharmacist that your medications will continue to be covered.

• Consider plans with lower-tier options for your prescriptions to save on costs.

Finding the Best Medicare Part D Plan for You

To choose the right Medicare Part D plan, take the following into account:

• Formulary Coverage: Ensure your medications are included.

• Cost Factors: Review deductibles, copays, and coinsurance.

• Pharmacy Network: Some plans offer lower prices at preferred pharmacies.

• Extra Perks: Some plans provide added services, like medication therapy management.

If you need help selecting a plan, speaking with a licensed agent listed on this website can ensure you make the best choice for your prescription needs.