Why Is Benzonatate Not Covered by Medicare?
Uncover why Medicare drug plans may not cover certain medications like Benzonatate and learn how to navigate your prescription coverage.
Medicare beneficiaries often find it challenging to understand prescription drug coverage, leading to questions about specific medications. Benzonatate, a common cough suppressant, frequently prompts inquiries regarding its inclusion within Medicare plans. Understanding Medicare’s prescription drug benefit structure and rules is essential for beneficiaries seeking clarity on coverage. This knowledge can explain why certain medications may or may not be covered and what steps can be taken to address these challenges.
How Medicare Drug Coverage Works
Prescription drug coverage under Medicare is primarily facilitated through Medicare Part D plans, which are offered by private insurance companies approved by Medicare. These plans each maintain a “formulary,” a comprehensive list of the prescription drugs they cover. The specific drugs included on a formulary can vary significantly from one plan to another, though all plans must cover at least two drugs per drug category.
Within each formulary, medications are categorized into different “tiers,” which dictate the cost-sharing amount for beneficiaries. Drugs in lower tiers, such as preferred generics, generally have lower out-of-pocket costs compared to those in higher tiers, like non-preferred brands or specialty medications. Formularies are subject to annual changes, and plans may also implement utilization management tools like quantity limits or prior authorization requirements for certain drugs. Certain drug categories are generally excluded from Part D coverage by law, including medications used solely for cosmetic purposes, fertility treatments, weight management, or those specifically for the relief of cold or cough symptoms.
Why Benzonatate Faces Coverage Issues
Benzonatate is a prescription medication used to alleviate cough symptoms. Its coverage under Medicare Part D plans is not universal and largely depends on the specific plan’s formulary. If a Part D plan classifies benzonatate strictly under the federal exclusion for cold or cough symptoms, it will not be covered.
Even if a plan does include benzonatate on its formulary, its cost to the beneficiary will be determined by its assigned tier. Placement in a higher, more expensive tier can result in substantial out-of-pocket expenses. Some plans may also require prior authorization or mandate “step therapy,” meaning beneficiaries might need to try other, often less costly, cough suppressants before benzonatate will be covered. The ultimate decision rests with individual private Part D plans, which consider factors like cost-effectiveness and negotiated prices.
Steps for Obtaining Benzonatate Coverage or Affordability
Medicare beneficiaries seeking coverage for benzonatate or aiming to manage its cost have several actionable options. First, review the current Part D plan’s formulary to determine if benzonatate is listed and its tier placement. If the drug is not covered, the Medicare Plan Finder tool on Medicare.gov can be utilized during the Annual Enrollment Period to compare other Part D plans in the beneficiary’s service area that may include benzonatate.
Discussing the medication with the prescribing doctor is important. The doctor might be able to provide a clinical justification for benzonatate, which can support a formulary exception request to the plan. Alternatively, the doctor could suggest a different, covered medication that serves a similar purpose. If coverage is denied, beneficiaries have the right to appeal the decision, a process that typically begins with the plan and can proceed to independent review entities. A letter of medical necessity from the doctor can strengthen an appeal.
Beyond insurance, exploring prescription drug discount cards or checking cash prices at local pharmacies can offer lower costs than insurance co-pays for non-preferred drugs. These discount cards cannot be combined with insurance benefits. Manufacturer-sponsored patient assistance programs or non-profit organizations may also provide financial aid for prescription costs, often based on income and insurance status.