Does Medicare cover over-the-counter drugs?

Does Medicare Part D cover over-the-counter drugs?

No, with one exception. CMS's Medicare Prescription Drug Benefit Manual says the definition of a Part D drug doesn't include over-the-counter products, so Part D plans can't cover them under their basic prescription drug benefit or as a supplemental benefit under enhanced alternative coverage. Nonprescription drugs are also on CMS's list of drugs excluded from Part D coverage.

The exception is insulin: CMS's coverage table lists nonprescription drugs as not covered under basic Part D, except insulin and supplies associated with the injection of insulin. Those supplies include:

• Syringes
• Alcohol wipes and alcohol
• Insulin pens and pen needles
• Gauze

Can a Medicare drug plan give me over-the-counter drugs at no cost?

Sometimes, as part of the plan's own drug management. CMS lets Part D plans provide over-the-counter drugs as part of their administrative costs. Part D plans may include over-the-counter drugs in step therapy protocols (rules that have you try a certain drug before the plan covers a more expensive one) as part of a cost-effective drug utilization management program, but CMS treats those over-the-counter drugs as administrative costs, not Part D drugs.

Under certain conditions, as part of a plan utilization management program, over-the-counter drugs can be provided at no cost to members, and the cost to the plan counts as an administrative cost.

What happens if my prescription drug becomes available over the counter?

When a drug on a plan's drug list (formulary) switches to over-the-counter status during the year, any existing stock of the prescription version still meets the definition of a Part D drug. CMS strongly recommends that plans notify affected members right away, and CMS directs plans to remove the prescription product from their formulary at the next formulary submission window after the over-the-counter product becomes available.

CMS says giving members the over-the-counter product at no cost doesn't satisfy its formulary requirements, so a plan may need to add other drugs to its formulary when it removes the drug. Your plan must notify you of changes to its drug list that affect drugs you're taking.

Do Medicare Advantage plans cover over-the-counter drugs?

Some may, as an extra benefit. The Medicare & You handbook says Medicare Advantage plans may cover some benefits Original Medicare doesn't, and some plans may cover things like rides to doctor visits and over-the-counter drugs that Part D doesn't cover. These benefits are generally limited, so check with the plan before you join to find out what exactly is covered and whether the benefits are available to you.

Medicare Advantage plans must cover all medically necessary services that Original Medicare covers, and rules and costs vary by plan. See what extra benefits Medicare Advantage plans can offer.

Does Original Medicare or Medigap pay for over-the-counter drugs?

Original Medicare's drug coverage is limited. Medicare Part B covers a limited number of outpatient prescription drugs under certain conditions, usually drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting. Medicare drug coverage (Part D) covers many drugs that Part B doesn't cover.

Medigap plans sold after 2005 don't include prescription drug coverage. To get drug coverage with Original Medicare, you can join a separate Medicare drug plan (Part D); see how Medicare covers prescription drugs.