Is Benzonatate Covered by Medicare?
Navigate Medicare's prescription drug coverage. Find out if Benzonatate is covered and what your costs could be.
Benzonatate is a non-narcotic medication used to relieve coughs caused by common colds or influenza. It functions by numbing the stretch receptors in the lungs and air passages, thereby helping to suppress the cough reflex. Medicare’s coverage for prescription drugs like Benzonatate can be intricate, as it depends on various components and specific plan details.
Medicare Part D and Prescription Drug Coverage
Medicare Part D covers outpatient prescription drugs. This coverage differs from Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance). Parts A and B generally do not cover medications dispensed for use at home, focusing instead on drugs administered during hospital stays or in a doctor’s office under specific circumstances, such as certain injectable medications.
Part D plans are offered by private insurance companies approved by Medicare. Individuals can enroll in a standalone Part D plan to supplement their Original Medicare, or they may receive prescription drug coverage as an integrated benefit within a Medicare Advantage Plan (Part C). These private plans are regulated by Medicare, but they each establish their own coverage terms and costs.
Factors Influencing Benzonatate Coverage
Whether Benzonatate is covered by your Medicare Part D plan depends on its formulary, a list of covered medications. If Benzonatate is not included on your plan’s formulary, it will not be covered, though you may request an exception or file an appeal.
Formularies categorize drugs into different tiers, impacting your out-of-pocket costs. Medications on lower tiers, often generics, have lower cost-sharing, while drugs on higher tiers, such as specialty medications, incur higher costs. Additionally, plans may implement utilization management restrictions for certain drugs, including Benzonatate. These restrictions can involve prior authorization, requiring your doctor to obtain approval from the plan before the drug is covered, or step therapy, where you may need to try a less expensive alternative medication first before the plan covers the prescribed drug.
Checking Your Plan’s Coverage
To determine if your Medicare Part D plan covers Benzonatate and its conditions, you can take several steps. Review your plan’s formulary, available on its official website. Formularies allow you to search for specific drugs, their tier placement, and any associated restrictions.
You can also directly contact your Part D plan by calling the customer service number provided on your member identification card. Plan representatives can provide details regarding Benzonatate’s coverage, including its cost-sharing tier and any requirements like prior authorization. Another valuable resource is the Medicare.gov Plan Finder tool, which allows you to compare plans in your area, input your current medications, and assess how different plans would cover them. This tool can help you identify plans that include Benzonatate on their formulary and understand the associated costs.
Understanding Your Out-of-Pocket Costs
Even when Benzonatate is covered by your Medicare Part D plan, you will incur some out-of-pocket expenses. These costs begin with an annual deductible, the amount you must pay for your prescriptions before your plan starts to contribute. For 2025, the maximum deductible for Part D plans is $590, though some plans may offer a lower deductible or none.
After meeting your deductible, you will pay either a co-payment, which is a fixed dollar amount for a prescription, or co-insurance, a percentage of the drug’s cost. A significant change for 2025 is the elimination of the coverage gap, often called the “donut hole.” Instead, once your total out-of-pocket spending on covered prescription drugs reaches $2,000 in a calendar year, you will enter the catastrophic coverage phase. In this phase, you will pay nothing for your covered medications for the remainder of the year.