InfoStat | 12-05-2013

Medicare Part D Coverage of Top 10 Prescription Drugs


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1 See section 20 “Part D Exclusions” within chapter 6 (Rev. 10, 02-19-10) of the Pub. 100-18 Medicare Prescription Drug Benefit Manual. Centers for Medicare & Medicare Services. September 26, 2008. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf. Last accessed November 11, 2013. Some state pharmaceutical assistance programs offer assistance with regard to Medicare Part D excluded drugs.
2 “Each category or class must include at least two drugs (unless only one drug is available for a particular category or class, or only two drugs are available but one drug is clinically superior to the other for a particular category or class), regardless of the classification system that is utilized. The two drug minimum requirement must be met through the provision of two chemically distinct drugs.” “30.2.1 - Formulary Categories and Classes” within chapter 6 (Rev. 10, 02-19-10) of the Pub. 100-18 Medicare Prescription Drug Benefit Manual. There are exceptions to the two drug minimum in cases where “unless only one drug is available for a particular category or class, or only two drugs are available but one drug is clinically superior to the other for a particular category or class.” Medicare also requires that all, or substantially all, of the drugs in the following 6 drug classes to be covered: Antidepressant medications, antipsychotic drug medications, anticonvulsant medications, antineoplastic drugs (used by cancer patients), immunosuppressant (used by transplant patients), and antiretroviral (used by patients with HIV).
3 The “catastrophic coverage” protection within the Medicare Part D program only applies to on-formulary medications for an enrollee within a Medicare drug plan. See “Understanding True Out-of-Pocket (TrOOP) Costs.” http://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11223-P.pdf. Last accessed December 3, 2013.
4 http://www.drugs.com/stats/top100/sales. Last accessed December 3, 2013. Drug sales are for all of the U.S. regardless of Medicare enrollment.
5 Some medications treat multiple conditions.
6 “Biologics for Rheumatoid Arthritis Treatment” http://www.webmd.com/rheumatoid-arthritis/guide/biologics. Last accessed December 3, 2013.