Prescriptions Covered by Medicare: What Drugs Does Medicare Pay For?

What prescriptions does Medicare Part D cover?

Medicare Part D is Medicare drug coverage for outpatient prescription drugs. It is offered through Medicare-approved private plans, either as a stand-alone drug plan or as part of many Medicare Advantage plans.

Part D plans must cover a wide range of prescription drugs commonly used by people with Medicare. This includes brand-name and generic drugs. Medicare says plans must also cover most drugs in certain protected classes, including drugs used to treat cancer, HIV/AIDS, and depression.

However, each Part D plan has its own covered drug list, called a formulary. A drug that is covered by one plan may not be covered the same way by another plan.

What is a Medicare drug formulary?

A formulary is the list of drugs a Medicare drug plan covers. Plans may include brand-name drugs, generic drugs, original biological products, and biosimilars.

Many plans group covered drugs into cost tiers. Drugs in lower tiers usually cost less than drugs in higher tiers. A plan may also have preferred pharmacies, mail-order options, or special rules that affect how much you pay.

Before enrolling in or staying with a plan, check whether your prescriptions are on the formulary and whether the plan has rules for those drugs.

What drugs does Medicare Part B cover?

Medicare Part B covers a limited number of outpatient prescription drugs under specific conditions. These are often drugs you would not usually give yourself, such as drugs given in a doctor’s office or hospital outpatient setting.

Examples of Part B drug coverage may include:

• Many injectable or infused drugs given by a licensed medical provider
• Certain drugs used with Part B-covered durable medical equipment, such as an infusion pump
• Some End-Stage Renal Disease drugs
• Immunosuppressive drugs after a Medicare-covered transplant, when Medicare rules are met
• Certain vaccines, such as flu, pneumococcal, and COVID-19 vaccines

If a drug is not covered under Part B, it may be covered under Part D if it is on your plan’s formulary or approved through an exception.

Are drugs covered during a hospital or skilled nursing facility stay?

Generally, drugs you receive as part of inpatient treatment during a covered hospital stay or skilled nursing facility stay are covered under Medicare Part A. In that situation, the drug is usually part of the covered inpatient care rather than processed through a Part D plan.

Rules can be different if you are in a hospital outpatient setting, such as observation status or an emergency department visit. Some self-administered drugs in outpatient settings may not be covered by Part B, and you may need to check whether your Part D plan will reimburse you.

What prescriptions are not automatically covered?

Medicare does not automatically pay for every prescription. Coverage depends on the part of Medicare involved, your plan’s formulary, where you receive the drug, and whether plan rules are met.

Common limitations include:

• A Part D plan may not cover a specific drug if it is not on the formulary, unless an exception is approved.
• A plan may require prior authorization before paying for a drug.
• A plan may require step therapy, meaning you try a lower-cost drug first, unless an exception is approved.
• A plan may set quantity limits, such as covering only a certain number of pills per month.
• Over-the-counter drugs are generally not covered by Medicare drug plans.

What if your prescription is not covered?

If your drug is not covered, you or your prescriber may be able to ask the plan for an exception. An exception is a plan decision to cover a drug that is not on its drug list or to waive a coverage rule.

Your prescriber usually must provide a supporting statement explaining why the drug or exception is medically necessary. If the plan denies the request, you may have appeal rights under Medicare rules.

You can also ask your prescriber whether a covered alternative, generic, or biosimilar may work for your condition.

How much will Medicare pay for covered drugs in 2026?

Your costs depend on your plan, pharmacy, drug tier, deductible, copayments, coinsurance, and whether you qualify for help with costs.

For 2026, Medicare says no Medicare drug plan may have a deductible higher than $615. After any deductible is met, you generally pay the plan’s cost sharing for covered drugs. Medicare also says yearly out-of-pocket costs for Part D-covered prescription drugs are limited to $2,100 in 2026. After reaching that limit, you pay nothing for covered Part D drugs for the rest of the calendar year.

These protections apply to Part D-covered drugs, not every medication or every cost related to health care.

Official Sources