Understanding Medicare Part D Coverage in Skilled Nursing Facilities

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Medicare Part D is a prescription drug coverage program offered by the federal government. It is designed to help Medicare beneficiaries afford the cost of their prescription medications. While Part D primarily covers prescription drugs obtained from pharmacies, there are certain exceptions and limitations that apply when it comes to coverage in skilled nursing facilities.

Medicare Part D Coverage in Skilled Nursing Facilities

  1. Eligibility Requirements: To be eligible for Medicare Part D coverage in a skilled nursing facility, you must first meet the criteria set forth by Medicare. Typically, this involves being enrolled in Medicare Part A or Part B, and also being prescribed medications that are covered under Part D.
  2. Medication Coverage: Under Medicare Part D, medications provided to individuals residing in skilled nursing facilities are generally covered. However, it’s important to note that Part D coverage is typically limited to drugs that are not covered by Medicare Part A or Part B.
  3. Prior Authorization: In some cases, prior authorization may be required for certain medications. Prior authorization is a process where the healthcare provider must obtain approval from Medicare before prescribing a particular drug. This is usually done to ensure the medication is medically necessary and appropriate for the patient’s condition.
  4. Formulary and Tiered Coverage: Medicare Part D plans have formularies, which are lists of drugs that they cover. These formularies often include different tiers, each with its own cost-sharing requirements. It’s essential to review the formulary of your Part D plan to understand the coverage and associated costs for the medications you need while in a skilled nursing facility.
  5. Extra Help: If you have limited income and resources, you may qualify for Extra Help, also known as the Low-Income Subsidy (LIS) program. Extra Help provides assistance in paying for prescription drugs, including those received in skilled nursing facilities. To determine your eligibility and apply for Extra Help, you can visit the Social Security Administration’s website.
  6. Coverage Gap (Donut Hole): It’s worth mentioning that Medicare Part D has a coverage gap, commonly referred to as the “donut hole.” The coverage gap is a temporary limit on what the Part D plan will cover for prescription drugs. Once you reach this limit, you may be responsible for a higher percentage of the drug costs until you reach catastrophic coverage. However, it’s important to note that the coverage gap is gradually being phased out under current legislation.


In conclusion, Medicare Part D coverage extends to prescription medications received in skilled nursing facilities, with certain considerations and limitations. Understanding the eligibility requirements, formularies, prior authorization, and potential assistance programs like Extra Help is crucial for individuals seeking coverage for their medications while residing in a skilled nursing facility.

Remember, it’s always advisable to review your specific Medicare Part D plan and consult with your healthcare provider or a Medicare representative to obtain accurate and personalized information regarding your coverage.


  • Medicare Part D provides prescription drug coverage for individuals in skilled nursing facilities.
  • Eligibility requirements, formularies, and prior authorization play a role in coverage.
  • Extra Help/Low-Income Subsidy may assist individuals with limited income and resources.
  • The coverage gap, or donut hole, is gradually being phased out.

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