Additional Coverage:
- 14 Prescription Drugs Medicare Part D Won’t Cover in 2026 (financebuzz.com)
Navigating Medicare Part D: What’s Covered and What’s Not in 2026
**Local seniors, listen up! ** Medicare Part D is a crucial lifeline for nearly 54.8 million older Americans, helping them manage the often-daunting cost of prescription medications.
That’s almost 80% of all Medicare enrollees relying on this vital program. However, keeping track of what’s covered can feel like a moving target, with rules and restrictions constantly evolving.
To help you avoid unexpected costs at the pharmacy counter, let’s take a closer look at some of the 2026 plan restrictions. Understanding these changes before you refill your next prescription can save you a significant amount of money and stress.
Demystifying Medicare Part D
Medicare Part D is the component of Medicare specifically designed to cover prescription drugs. These plans are offered by private insurers like Humana, Aetna, and UnitedHealthcare, all of whom must adhere to federal guidelines regarding medication coverage and formulary management (the list of covered generic and brand-name drugs).
Generally, Part D assists with the cost of prescriptions filled at a pharmacy, and each plan utilizes a tier system to determine your out-of-pocket expenses. For example, a typical tier structure might look like this:
- Tier 1: Lowest Copayment – Reserved for preferred drugs, often common generics.
- Tier 2: Medium Copayment – Covers a wide range of generic medications.
- Tier 3: Higher Copayment – Includes common or “preferred” brand-name drugs and some higher-cost generics.
- Tier 4: High Copayment – For non-preferred drugs, both brand-name and generic.
- Tier 5: Highest Copayment – The specialty tier for unique and exceptionally high-cost brand and generic drugs.
Enrolling in Part D
You can enroll in Medicare Part D when you first become eligible for Medicare, typically at age 65, or during the annual open enrollment period. Most enrollees will pay monthly premiums, deductibles, and cost-sharing amounts, which vary based on their specific plan.
What Does Part D Actually Cover?
Part D generally covers FDA-approved medications that are deemed medically necessary to treat conditions and are listed on your plan’s formulary. Plans are mandated to cover drugs in “protected classes,” such as antidepressants, anticonvulsants, antiretrovirals, immunosuppressants, antipsychotics, and anticancer drugs.
The Mystery of Excluded Medications
Is there a comprehensive list of all medications excluded from Part D? The short answer is no.
Instead, Medicare requires plans to exclude entire categories of drugs, such as those used for weight management, cosmetic purposes, or erectile dysfunction. Plans may also opt to exclude certain brand-name drugs if more affordable biosimilars (highly similar versions of a biologic drug) are readily available.
Prescription Drugs Not Covered by Medicare Part D in 2026
While this list isn’t exhaustive, here are some commonly prescribed drugs that are generally not covered by Medicare Part D in 2026. Many of these exclusions have been in place for years:
- Humira: Once a staple, many Part D plans are now steering away from brand-name Humira in favor of lower-cost biosimilars to reduce expenses. If prescribed Humira, you could be looking at an out-of-pocket cost of around $6,922 a month, or you may need to switch to a generic alternative.
- Viagra, Cialis, and other ED treatments: Medications for erectile dysfunction are broadly excluded from Part D. However, in specific, limited cases, a generic version might be approved if prescribed for medical conditions unrelated to ED, such as pulmonary hypertension.
- Wegovy, Ozempic (for weight loss), Xenical, and other weight-loss drugs: Medications used solely for weight loss are entirely excluded from Medicare Part D. It’s important to note that Ozempic and similar drugs may be covered if prescribed for the treatment of Type 2 diabetes.
Without coverage, patients could face monthly costs of approximately $1,350 for Wegovy or up to $900 for a 90-day supply of Xenical.
- Finasteride, Minoxidil, and other hair loss medications: Drugs used solely for cosmetic purposes, like treating hair loss, are not covered under Part D.
These out-of-pocket costs could range from $100 to $250 per month.
- Renova and other cosmetic drugs: Similar to hair loss treatments, medications prescribed purely for cosmetic reasons, such as Renova (for wrinkles or skin tone), are excluded.
Medicare only covers drugs deemed medically necessary. Renova could cost $70 to $160 monthly without coverage.
- Prescription Robitussin AC, Phenergan, and other acute cough medications: Part D generally does not cover prescription cough syrups. These are often excluded as short-term, symptomatic treatments that don’t meet Medicare’s criteria for covered prescription benefits.
- Doctor-prescribed OTC drugs (Miralax, Claritin, Tylenol): Even with a doctor’s prescription, over-the-counter products like Miralax, Claritin, or Tylenol are not covered by Medicare Part D. However, if a higher-dose, prescription-only version of an OTC medication is prescribed, that specific exclusion might not apply.
- Prescription eyeglasses or corrective lenses: Part D does not cover routine eye exams, eyeglasses, or contact lenses. However, medications used to treat eye diseases are covered.
Previously Covered Drugs May See Changes
Be aware that some high-cost brand-name drugs may face tighter restrictions in 2026. Others might remain covered but could be subject to new requirements like step therapy (trying a less expensive drug first), prior authorizations, or a mandate to try generics before brand-name options.
What If Your Medication Isn’t Covered?
Don’t panic if your medication isn’t covered. You have options!
Your doctor can request an exception, suggest a covered alternative, or help you appeal the denial. In situations of medical necessity (for example, if you cannot tolerate a cheaper alternative), Part D may still approve non-formulary medications.
Alternatives to Part D
If your medication remains uncovered, consider exploring other avenues to save money. GoodRx discounts, manufacturer coupons, and pharmacy discount programs can significantly reduce costs.
Some patients even find more affordable options through pharmacies in Canada or other countries. Additionally, switching to a different Part D plan during open enrollment could lead to better coverage and lower costs for your specific prescriptions.
The Bottom Line
Medicare Part D provides robust coverage for many medications, but it consistently excludes prescriptions for weight management, sexual dysfunction, and vitamins/minerals. As more plans prioritize generics to control costs, expect coverage to continue evolving.
Staying informed is key to managing your prescription expenses and making smart financial decisions. While the 2026 enrollment window has closed, eligible participants can still sign up, though a late enrollment penalty of an extra 1% for each month (or 12% annually) may apply. You can avoid this penalty if you had comparable “creditable drug coverage” before your late Part D enrollment.
Smart Money Moves for Everyone:
No matter your financial situation, there’s always room to improve your finances and boost your wealth. Here’s a quick guide to get you started:
- **Increase your income. ** If bills are tight, explore side hustles that fit your schedule or legitimate ways to boost your bank account.
- **Grow what you have. ** Time and compound interest are powerful allies.
Start by assessing your current financial standing to create a solid action plan. Consider working with a financial professional to ensure you’re on track for a comfortable retirement.
- **Seize opportunities. ** Maximize your senior benefits by taking advantage of all available deals, discounts, and money-saving opportunities.
If you own a car, shop around for the best auto insurance rates – it could save you hundreds! Conversely, be vigilant about avoiding money-wasting traps that can silently drain your bank account.
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- 14 Prescription Drugs Medicare Part D Won’t Cover in 2026 (financebuzz.com)