Medicare Coverage for Antidepressants

There are six classes of prescription medication that Medicare requires all Part D plans to cover. Medicare members with a Part D plan are guaranteed access to their prescriptions in these classes, known as “protected classes.”

Antidepressants are one of the six protected classes. This means that all Medicare prescription drug plans have coverage for antidepressants. The other protected Medicare prescription classes are:

• Anticonvulsants: Medications to treat seizures.
• Antineoplastics: Medications that treat cancer (chemotherapy).
• Antipsychotics: Medications to treat psychosis and schizophrenia.
• Antiretrovirals: Medications to treat viral infections, primarily HIV.
• Immunosuppressants: Medications that suppress the immune system, used to help prevent the rejection of transplanted organs.

Your antidepressant will need to be prescribed by your doctor to qualify for Medicare coverage. You’ll need to be under the care of a doctor and have your prescription renewed regularly. You’ll also need to have a diagnosis of depression and be prescribed a Food and Drug Administration (FDA) approved antidepressant. Medicare doesn’t generally pay for experimental or alternative treatments.

Not every plan will cover every possible antidepressant, but because antidepressants are a protected class, most antidepressants are covered by all Part D plans. In some cases, you might need to switch from a brand name to the generic form or search your area for a Part D plan that does include your specific antidepressant coverage. Your doctor or pharmacist might be able to guide you on the Part D plan that covers your antidepressant.

Your cost for antidepressants will depend on several factors. The cost of generic antidepressants, for example, is significantly less than the brand name.

The commonly prescribed antidepressant Zoloft can cost as much as $325 for the brand name. The generic form of Zoloft, sertraline, on the hand, costs between $7 and $30, even without insurance coverage.

Whether you use the brand name or generic makes a difference when you use insurance, including Medicare. You’ll pay a higher copayment for a brand name prescription than a generic one. This is because prescription drug plans have a list of covered prescriptions called a formulary. A formulary not only lists all the prescriptions a plan will cover but splits prescriptions into five categories, called tiers.

The drug plan tiers are:

• Tier 1: preferred generic drugs
• Tier 2: generic drugs
• Tier 3: preferred brand name drugs
• Tier 4: brand name drugs
• Tier 5: specialty drugs

You’ll have a higher copayment or coinsurance when your prescription falls on a higher tier. Often copayments on tier 1 can be less than $5, while copayments on tier 4 can include a 40 percent coinsurance cost.

Every plan structures this a little differently, and your costs often depend on your premium and deductible. However, an example formulary structure would look similar to this:

• Tier 1: $3 copayment
• Tier 2: $15 copayment
• Tier 3: $45 copayment
• Tier 4: 40 percent coinsurance
• Tier 5: 40 percent coinsurance

So, let’s look at Zoloft again. The generic form, sertraline, is often a tier 1 prescription, meaning you’d pay $3 after your deductible. If the brand name Zoloft was a tier 4 drug on your plan, you’d pay 40 percent of the retail price of $325, or about $130. The same holds true for most antidepressants. You’ll save money by taking the generic form.

You’ll need a Medicare plan that covers prescriptions to get coverage for antidepressants. Generally, this means you’ll need a Medicare Part D plan or a Medicare Advantage plan that includes Part D coverage. You can read about antidepressant coverage in each part of Medicare below.

• Part A. Medicare Part A is hospital insurance. It doesn’t generally cover prescriptions unless you received them while you’re receiving inpatient care such as in a hospital, nursing home, or rehabilitation facility. Part A will cover your antidepressant while you’re receiving inpatient care, but won’t cover them when you return home.
• Part B. Medicare Part B is medical insurance. It covers things like doctor visits, emergency room visits, urgent care, and ambulance rides. It doesn’t generally cover any prescriptions, including antidepressants.
• Part C. Medicare Part C is also known as Medicare Advantage. It covers everything that parts A and B do, and often includes additional coverage. When this additional coverage includes Part D, antidepressants will be covered.
• Part D.Medicare Part D is prescription drug coverage. All Part D plans are required to cover antidepressants.
• Medigap. Medigap is supplemental insurance that covers some of the out-of-pocket costs of Medicare parts A and B. It covers things like deductibles and copayments. It doesn’t offer coverage for prescriptions, including antidepressants.