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.

Automatic-refill mail order service for prescription drugs 

Some people with Medicare get their prescription drugs by using an “automatic refill” service that automatically delivers prescription drugs when you’re about to run out. However, in the past, some prescription drug plans weren’t making sure over time that some customers still wanted or needed a prescription drug. Since pharmacies can’t restock the prescription drug if it's sent through the mail and generally won’t cancel the order, some automatic delivery services were creating significant waste and unnecessary additional costs for people with Medicare and the Part D program.

To make sure you still need a prescription before they send you a refill, prescription drug plans should get your approval to deliver a prescription, new or refill, before each delivery, except when you yourself ask for the refill or request a new prescription. This may be a change for you if you've always used mail-order in the past and haven't had the opportunity to confirm that you still need refills. Be sure to tell your drug plan the best way to reach you so you don't miss the refill confirmation call or other communication. The plan won’t automatically ship your refills unless you confirm you still want to get the order. This new policy won’t affect refill reminder programs where you go in person to pick-up the prescription and it won’t apply to long-term care pharmacies that give out and deliver prescription drugs.

Contact your plan if you get any unwanted prescription drugs through an automated delivery program. You may be eligible for a refund for the amount you were charged. Call 1-800-MEDICARE if you experience any problems using automatic delivery and billing.