Drugs Part D can never cover, by law — and what to do instead
Checked against the current rules on September 25, 2026.
Some Part D denials aren't really about formulary status, tiering, or medical necessity at all — the drug is categorically excluded from Medicare Part D coverage by law, and no appeal, however well-documented, can overturn that.
Source: Medicare Prescription Drug Benefit Manual Ch. 6 — Part D Drugs and Formulary Requirements (Rev. 18, 01-15-16).
Part D excludes coverage for drugs used for weight loss or weight gain, fertility, cosmetic purposes or hair growth, symptomatic relief of coughs and colds, and most prescription vitamins and minerals (except prenatal vitamins and fluoride preparations), among other statutory exclusions.Part D Exclusions
The same statutory exclusion list also covers non-prescription (over-the-counter) drugs, barbiturates, benzodiazepines in some circumstances, and drugs for erectile or sexual dysfunction — the exclusion is tied to the drug's use and category under the statute, not to any individual plan's own formulary choices, which is exactly why no plan can voluntarily choose to cover them under the standard Part D benefit.Part D Exclusions
Why this is worth checking carefully before assuming it applies
A denial notice that just says "excluded drug" or cites a formulary exclusion isn't automatically a statutory exclusion — plans also maintain their own formulary exclusion lists for non-statutory reasons (a therapeutically equivalent alternative exists, cost management, a step-therapy requirement), and those ARE appealable through the ordinary exceptions process described elsewhere in this pack's own rules pages.
Some drugs statutorily excluded from the standard Part D benefit can still be covered as a plan's own supplemental benefit if the plan has chosen to offer that — so the same drug denied as "not covered" by one plan may be covered, at extra premium cost, by a different Part D plan's enhanced benefit design during the next enrollment period.
What this means for your appeal
If a denial notice cites one of these categories, filing a formulary or tiering exception won't help — the honest next step is a manufacturer patient-assistance program, the plan's own supplemental benefits if any exist, or paying out of pocket, not an appeal that can't legally succeed.
Before accepting that conclusion, confirm the denial notice actually cites a statutory exclusion by name (or by a code that maps to one) rather than a generic "not on formulary" reason — the two look similar to a family reading a denial letter for the first time, but only one of them forecloses an appeal entirely.
Sources — last checked September 25, 2026
- Part D Exclusionsas of September 25, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
