I'm getting conflicting information about whether Medicare covers my specific medication. How can I get a definitive answer?

Question

Aaron Solomon · Accepted Answer

There are 2 ways. You can work with an agent. He can look up all your drugs. He can look at each companies formulary. The second option is to look it up on the Medicare site

Melonie Wood · Answer

This is why it is so important to actually meet with an agent in person who has several carriers they write for. The agent can put the members in the carrier's formulary to make sure the medication is covered

Answered by Melonie Wood on April 4, 2025

Agent Licensed in FL & AL

Answered by Melonie Wood Medicare Insurance Agent

Clarence &quot;Mark&quot; Christiansen · Answer

Go to this public web site: medicare.gov, click "Find a Plan Now" then key in your zip code and medications. Follow the prompts.

Tasha Riggs · Answer

It will depend on your plan that you pick. The cost and coverage will be different based on the Drug card you buy or the Medicare Advantage plan you buy.

Robert Moore · Answer

Medicare Parts A and B will cover certain drugs.  There are stipulations of course.  The best way to be certain is to call the Centers for Medicare Services or your local Medicare broker.

Tracy Briley · Answer

All medications can be checked at medicare.gov.

This is the most thorough way that you're going to find out if it's covered.
Formularies change quite often with pharmaceuticals in medicare.So you want to make sure that whatever plan you have covers it as well.

Steven Bleicher · Answer

Every Advantage plan and every Part D plan has a drug formulary containing all the drugs that the plan covers. However, in our current global economy, that list will be very unreliable, I'm sorry to say! That is why you must check with the wide variety of online US and Canadian discount websites which can save you the copay money. The most popular of which is GoodRx.com. The maximum out of pocket cost for ALL of the drugs you take is $2,000 this year. Medicare keeps track of this. But if you use a Canadian pharmacy, the expense in using them won't be applied toward that deductible. Then in each calendar year, it begins all over again.

Answered by Steven Bleicher on May 28, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Dana Dane · Answer

Please contact your insurance agent for assistance.  If you don't have an agent, please contact your prescription insurance company.

Barbara Barnes, CMIP® · Answer

The only truly definitive answer comes at the pharmacy when you pick up your medication. Accurate answers before you pick up your medication may come from your insurance company. You may call their customer service line to discuss your medication questions and coverage provisions. They will help you to know if the medication is on-formulary and if any extra approval is required through prior-authorization or step therapy. You can also ask them if there are similar medications that would be covered at a lower cost so that you may discuss those options with your doctor or pharmacist. If they are telling you something different than you expect, you can ask to speak to a supervisor to figure out why you’re getting a different price quote or coverage determination from your pharmacy or from their online formulary tool. 

Every detail matters with Part D coverage - drug, dosage, formulation, quantity, diagnosis, pharmacy, specific plan, how much you’ve anlready spent toward your MOOP and prior-authorizations. Only when all of these factors align correctly can you rely on the quoted price as ‘definitive’.

Tammy Stoner · Answer

If enrolled in a Medicare Advantage plan, contact your member services. If the drug is not on formulary, then the Dr. will need to submit a formulary exception.

If you have a stand alone drug plan, contact them directly. Again, a formulary exception may be required.

Mal Varlack · Answer

Each Medicare Plan has a “formulary”, which is a document that states which medications are covered in part or fully by that particular plan. You can either call Member services on the back of the card and speak to a representative or call your broker who can also look up your plan and give you the answer as you both go over your medications.

Answered by Mal Varlack on April 17, 2025

Agent Licensed in FL

Answered by Mal Varlack Medicare Insurance Agent

Gary Henderson · Answer

Sign onto medicare.gov follow the steps for prescription drug plans. Enter in the medication you're taking and it will tell you what the coverage is for that particular medication 
There are many Medicare plans for prescriptions out there. Most of them will cover the majority of drugs 
There's also a annual $2,000 limit now out of pocket so you cannot exceed that with any company that you work with

Jerry Cohen · Answer

Medicare does not actually provide prescription coverage the specific plan you are enrolled in has what is known as a formulary. You cneither look at the formulary and see if your medication is covered or you can call customer service at the company you are covered by. If you have not obtained coverage yet you can go to the Medicare.gov website and look at the all the presciption plans for the area you live in. You can input the name and dosage of the medication you are covered by and see if it comes up with any of the plans available.

Answered by Jerry Cohen on May 5, 2025

Broker Licensed in NY

Answered by Jerry Cohen Medicare Insurance Agent

Sonya Chandler · Answer

You can go to the Plan's website. You can also contact the Insurance Plan directly and ask about the medication. You can also go to Medicare's website and look the medication up. You can also ask your Insurance Agent for help.

Answered by Sonya Chandler on May 21, 2025

Agent Licensed in NY, AZ, FL & 5 other states

Answered by Sonya Chandler Medicare Insurance Agent

Toni Chavez · Answer

Sorry to hear you’re getting a conflicting answer.  

Several options call you plan carrier they can advise from the drug formulary.

You should have received the drug formulary in the mail when you received your 2025 Plan Documents. 

You can look the drug up on the formulary, it will give you the tier and then you see what the cost is for that tier with your drug plan.

The most you will pay for all drugs out of pocket this calendar year for 2025
Is 2,000

Speak with your broker and they can check 

Visit Medicare.gov 

My highest recommendation is call your agent,  if you don’t have an agent you can always get one so in the future you have an advocate that can assist you.

Hope this helps!

Thanks,
Toni Chavez
Medicare Broker

Betty McCarty · Answer

This depends on the type of Medicare drug plan you have. All Medicare drug plans have a formulary. A Medicare formulary is essentially a list of prescription drugs that a Medicare drug plan covers. Contact your Medicare Plan provider and request a drug formulary. I will be happy to assist you if you have more questions.

Answered by Betty McCarty on April 5, 2025

Agent Licensed in WA

Answered by Betty McCarty Medicare Insurance Agent

Fran Lovelace · Answer

Medications are covered by either a stand alone prescription drug plan or a prescription plan embedded in a Medicare Advantage plan.  You should check your plan's formulary.

Brianna Douros · Answer

How are you getting conflicting information? From your agent? From a website? I would call the specific company you are planning to go with so they can clarify.

Kristen Maurice · Answer

All Part D plans have their own drug list, or formulary. To get a definitive answer as to whether or not a drug is covered by a particular plan, it is best to check the formulary of the plan you are looking to enroll in. All Part D plans must post their formularies online for the public. You can find the formulary for a particular plan by putting the plan name and your state into a search engine.

Answered by Kristen Maurice on June 9, 2025

Agent Licensed in TN, AL, CA & 10 other states

Answered by Kristen Maurice Medicare Insurance Agent

I'm getting conflicting information about whether Medicare covers my specific medication. How can I get a definitive answer?

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