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MMA Frequently Asked Questions:
Medicare Part D - Drug Coverage and Exclusions

 

1. What is changing?

Beginning January 1, 2006 people who have Medicaid and Medicare coverage (dual eligibles) will begin receiving all covered prescription drugs through private companies contracted with Medicare. Medicaidwill not cover any prescription drugs that Medicarecovers.


2. Why is this happening?

In December 2003, the Medicare Modernization Act (MMA) created the new, voluntary Medicare prescription drug benefit, Medicare Part D. States can no longer receive federal funds to provide prescription drugs for dual eligible clients.


3. What drugs are covered?

Medicare Part D plans pay for the following (including a minimum of 2 drugs per every category/class of drugs):

  • Prescription drugs;
  • Biological products (e.g. Procrit for certain diagnoses);
  • Insulin & Supplies (e.g. syringes, needles, alcohol swabs, and gauze);
  • Vaccines (e.g. Hepatitis B vaccine for low risk individuals), and
  • Smoking cessation agents.

MedicarePart D plans must cover the majority of the following drugs:

  • Anti-convulsants (e.g. seizure drugs);
  • Anti-depressants;
  • Anti-neoplastics (e.g. cancer drugs);
  • Anti-psychotics;
  • Anti-retrovirals (e.g. HIV/AIDS drugs), and
  • Immunosuppressants (e.g. transplant drugs).

4. What drugs are excluded?


MedicarePart D plans cannot cover the following:

  • Drugs for anorexia, weight loss, or weight gain;
  • Drugs used to promote fertility;
  • Drugs used for cosmetic purposes or hair growth;
  • Prescription cough/cold drugs & prescription vitamins/minerals (except prenatal vitamins and fluoride preparations);
  • *Barbiturates, over-the-counter (OTC) drugs, and Benzodiazepines.
    (*Medicaid will still cover barbiturates, OTCs, and benzodiazepines.)