why are generic meds not covered by medicare

The drug hasn’t been approved by the U.S. FDA or is experimental. The health plan has concerns about the safety or effectiveness of the drug. The drug is considered a “lifestyle” drug and therefore not medically necessary.

Full Answer

What drugs are covered by Medicare drug plans?

Most Medicare drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage.

Are generic drugs the same as brand name drugs?

Generic drug makers must prove to the FDA that their product works the same way as the brand-name prescription drug. In some cases, there may not be a generic drug the same as the brand-name drug you take, but there may be another generic drug that will work as well for you.

Can drug plans remove brand name drugs from Medicare formularies?

For 2019 and beyond, drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs.

Does Medicare cover non-FDA approved drugs?

If your doctor prescribes a non-cancer medication on your plan’s formulary for a reason other than the use approved by the FDA, your drug will probably not be covered unless the use is listed in one of three Medicare-approved drug compendia (medical encyclopedias of drug uses).

What are the disadvantages of generic?

Cons of generic drugs:Patients perceive them as inferior to branded drugs.If they're not co-formulated, higher pill burdens may deter adherence.Overall co-payments for a regimen could result in higher costs to patients.They may have a different pill size/color when generic suppliers change.More items...•

What drugs does Medicare not pay for?

Medicare does not cover:Drugs used to treat anorexia, weight loss, or weight gain. ... Fertility drugs.Drugs used for cosmetic purposes or hair growth. ... Drugs that are only for the relief of cold or cough symptoms.Drugs used to treat erectile dysfunction.More items...

Why we should not use generic medicine?

The generic has to have the same active ingredients and in the same amount as the original. But the other ingredients in the pill, such as fillers, can be different. And that can affect how quickly the medication gets absorbed by your body, Cooperman explains.

Why do insurance companies prefer generic drugs?

It's also common for multiple companies to sell the same generic drug. This creates competition and results in lower prices. Generics generally cost up to 85% less than their brand-name versions. They have the same active ingredients and the same strengths.

Why do doctors not like Medicare Advantage plans?

If they don't say under budget, they end up losing money. Meaning, you may not receive the full extent of care. Thus, many doctors will likely tell you they do not like Medicare Advantage plans because private insurance companies make it difficult for them to get paid for their services.

Is it worth getting Medicare Part D?

Most people will need Medicare Part D prescription drug coverage. Even if you're fortunate enough to be in good health now, you may need significant prescription drugs in the future. A relatively small Part D payment entitles you to outsized benefits once you need them, just like with a car or home insurance.

Can you trust generic drugs?

According to the FDA, generic drugs can be trusted to have the same quality as brand-name drugs -- but at a cheaper price. That's important to know because no one wants to skimp on health, even if it means saving money.

What pharmacy has the best generics?

Walgreens. These guys win the prize for sheer volume of generics available coupled with a clear list that includes a tiered pricing system that is easy to understand.

Why do doctors prescribe generic drugs?

Generic drugs are a boon in health care. Typically lower in cost and as effective as their branded counterparts, they help control pharmacy spending and increase access to important therapies for patients who could be deterred by the high cost of some branded drugs.

Is GoodRx only good for generic drugs?

In order to help people afford their brand-name drugs, last May, we launched the InsideRx program on GoodRx that offers an average of 34% off over 100 brand-name prescriptions. Today, we are excited to announce discounts on even more brand-name drugs.

Is brand name medication better than generic?

So the question now is, if your doctor or pharmacist offers you a generic form of your current medication, should you take it? The short answer in most cases is, yes. "Brand-name medications are not always better. Many of them are highly expensive," says Dr.

Which is better generic or brand name drugs?

Fast facts: generic and brand-name medications A brand medication is the “innovator” or pioneer, and gets patent and exclusivity protection so generics can't compete right away. Generic medications must meet the same quality, strength, and purity standards as brands, so they have the same benefits and effects.

What happens if you don't use a drug on Medicare?

If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money.

How many prescription drugs are covered by Medicare?

Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per ...

What is formulary exception?

A formulary exception is a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule. A tiering exception is a drug plan's decision to charge a lower amount for a drug that's on its non-preferred drug tier.

What does Medicare Part D cover?

All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary.

How many drugs does Medicare cover?

All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer. The formulary might not include your specific drug. However, in most cases, a similar drug should be available.

What is a tier in prescription drug coverage?

Tiers. To lower costs, many plans offering prescription drug coverage place drugs into different “. tiers. Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier. ” on their formularies. Each plan can divide its tiers in different ways.

What is a drug plan's list of covered drugs called?

A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

What is Medicare Part A?

Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) are national health insurance programs available to people over 65. Together, they’re known as original Medicare. They only offer some drug coverage:

Does Medicare cover all drugs?

Many drugs are available through Medicare Part D coverage. However, because Medicare Part D coverage is offered through private companies, not all plans cover all drugs. Plan pricing and formularies, or lists of drugs covered by the plan, vary by company.

What is a fertility drug?

Fertility drugs. Drugs used for cosmetic purposes or hair growth. Note: Drugs used for the treatment of psoriasis, acne, rosacea, or vitiligo are not considered cosmetic drugs and may be covered under Part D. Drugs that are only for the relief of cold or cough symptoms. Drugs used to treat erectile dysfunction.

Is a cold covered by Part D?

For example, a medicine for the relief of cold symptoms may be covered by Part D if prescribed to treat something other than a cold —such as shortness of breath from severe asthma—as long as it is approved by the U.S. Food and Drug Administration (FDA) for such treatment.

Does Medicare cover AIDS?

There are certain kinds of drugs that are excluded from Medicare coverage by law. Medicare does not cover: Note: Part D may cover drugs used to treat physical wasting caused by AIDS, cancer, or other diseases.

What drugs does Medicare not cover?

Drugs not covered by Medicare Part D. In general, most Part D plans do not cover: drugs for hair growth. fertility drugs. over-the-counter drugs. medications covered by Medicare parts A and B. medications for erectile dysfunction. weight management medications.

What is the difference between coinsurance and deductible?

Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.

What is the Medicare Part B copayment?

For Medicare Part B, this comes to 20%. Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

Do you pay less for lower tier drugs?

Usually, a person will pay less for medications classified in lower tiers. Plan providers must make their formularies available so that people can compare their drug availability. Medicare rules require Part D plans to cover at least two drugs in the most commonly prescribed categories.

Does Part D cover the same medication?

Often, this will be a brand-name drug and its generic version, which is typically more affordable. Each plan can differ and not cover the same medications. This means that a person may have a particular drug covered in one Part D plan but not another. Plans may change their formulary at any time.

Does Medicare cover Part D?

Private Medicare-approved insurance companies administer these plans. When it comes to coverage, the federal government sets guidelines for insurance companies to follow , but the companies can decide which drugs their plans will cover. The lists of drugs covered may often vary. Costs for Part D plans also vary.

Does Medicare cover prescription drugs?

Medicare Part D prescription drug plans cover many prescribed medications. However, coverage may not be available in some instances. This could be due to drug type, cost, or regulation. Original Medicare includes Part A, which covers the medications a person receives when they are an inpatient at a hospital, and Part B, ...

What to do if your medication is not covered by Medicare?

5 options for medications not covered by Medicare. 1. Ask the doctor about generics or substitutes. Multiple medications can often have similar effects. If the brand drug isn’t covered, ask the doctor if there are any generic medications that would work just as well.

What to do if your medication isn't covered?

If your older adult’s medication isn’t covered, use these 5 options to get the drugs they need at the lowest cost possible. 1. Ask the doctor about generics or substitutes.

What is formulary in Medicare?

Each plan has a list of drugs that the plan will pay for, called a formulary. A big problem is that these formularies don’t cover everything and change constantly. A new medication your older adult’s doctor prescribes might not be covered.

What to ask when choosing a new drug plan?

Pro tip: When you’re choosing a new drug plan, ask the doctor which of your older adult’s medications must be a specific brand and which are OK as generics or substitutes (some drugs types are more sensitive than others). That gives you more flexibility to find a plan that covers all the medications your senior needs.

What is a formulary for Medicare?

The patient will usually pay for their annual deductible and 20% of the amount approved by Medicare. A formulary is a tiered list of covered drugs. Each prescription drug plan has its own formulary, and costs and coverage can vary from plan to plan. Check with your Part D to check on specific drugs.

How often should you review your prescription drug formulary?

Drugs may also be removed from coverage or replaced with similar medications. For these reasons, it is a good idea to review the formulary at least annually to validate the status of your prescribed medications.

What is Medicare Part D?

Medicare Part D is the prescription drug coverage arm of Medicare. Original Medicare focuses on inpatient hospital care and doctor visits under Part A and Part B, but it does not include any prescription drug coverage.

Does Medicare cover outpatient prescriptions?

Medicare Part B can help cover medications administered in a doctor’s office or outpatient setting. Part B Drug Coverage. Part B provides outpatient prescription drug coverage with specific limitations. This applies mostly to drugs that patients would not typically self-administer.

Take our quiz

Navigating Medicare can be challenging, especially since different types of coverage won’t necessarily cover all of your expenses. Choosing to purchase additional coverage may help. Find out which supplemental coverage option is best for you, Medicare Advantage or Original Medicare with Medigap.

Should I get additional Medicare coverage?

Navigating Medicare can be challenging, especially since different types of coverage won’t necessarily cover all of your expenses. Choosing to purchase additional coverage may help. Find out which supplemental coverage option is best for you, Medicare Advantage or Original Medicare with Medigap.

Why isn't my drug on my health plan?

Why Your Drug Isn’t on Your Health Plan Drug Formulary. Your health insurance plan’s Pharmacy & Therapeutics Committee might exclude a drug from its drug formulary a few common reasons: The health plan wants you to use a different drug in that same therapeutic class. The drug is available over-the-counter. The drug hasn’t been approved by the U.S.

Why do health plans want you to use different drugs?

One drug may have a better safety track record, fewer side effects , or be more effective than its competitor. However, the cost is the most common reason your health plan wants you to use a particular drug and leaves competing drugs off ...

What is a drug formulary?

A drug formulary refers to the list of drugs that a particular health insurance plan will cover. Has your doctor prescribed a drug that’s not on your health plan's drug formulary? Many people are shocked to learn their health plan has a list of drugs it will pay for (or count towards your deductible, if you have to meet it first);

Is a drug over the counter?

The drug is available over-the-counter. The drug hasn’t been approved by the U.S. FDA or is experimental. The health plan has concerns about the safety or effectiveness of the drug. The drug is considered a “lifestyle” drug and therefore not medically necessary.

Can you exclude a drug from the formulary?

Instead, excluding a drug from its formulary is more like saying that it won’t pay for that particular drug. You may still have it if you or someone else pays for it. It’s also possible to convince your health plan to pay for a drug that isn’t on its formulary, as there's an appeals process and you and your doctor can use if your doctor believes ...