Does Medicare Cover Omeprazole? 

When you eat, food is digested with the help of secretions from gastric glands, enzymes, and microbes. For instance, enzymes lining the stomach, proton pumps, assist in acid production and serve an essential role in the digestive process. Hydrochloric acid destroys microbes in food and helps enzymes break down food.

However, enzymes can lose effectiveness if the environment is too acidic. Too much acid can cause conditions like indigestion, acid reflux and heartburn. Indigestion presents as pain or a burning feeling in your upper abdomen. Acid reflux is when the mixture of food and acid back up from the stomach into your esophagus. Heartburn is a form of acid reflux, producing a burning sensation in your esophagus, which worsens when you lie down or bend over.

Omeprazole is an oral prescription medication belonging to a class of drugs called proton pump inhibitors that reduce stomach acid production.

Medicare coverage for omeprazole

If you enrolled in Medicare Part D, review your plan to check for omeprazole coverage. Your policy should provide online or hard-copy access to a formulary, a list of covered drugs. Your cost-sharing for prescription drugs depends on your policy’s deductible, copayments and coinsurance. You may have a lower cost if you are in a catastrophic drug phase, use a preferred pharmacy or qualify for the Extra Help program.

Dexlansoprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole are examples of other proton pump inhibitors. If your prescription plan does not cover omeprazole, ask your doctor if another drug is equally effective.  

Medicare coverage of over the counter drugs

The Food and Drug Administration (FDA) approved Prilosec OTC (omeprazole) as a nonprescription medication to treat frequent heartburn, meaning you experience heartburn at least two days per week. The drug is not for immediate relief of heartburn that happens occasionally. Over-the-counter (OTC) products designed for immediate heartburn relief include Pepcid, Tagamet and Axid.

Medicare Part D Prescription Drug Plans (PDPs) do not offer OTC benefits. Part D only covers drugs you purchase with a prescription and take under a doctor’s supervision. However, many Medicare Advantage (MA) plans offer extra benefits that may include an allowance for OTC products. MA plans with OTC benefits typically provide a catalog of eligible items, information on spending limits, and instructions on how to order from the network provider.  

Part D enrollment

Although Medicare encourages beneficiaries to sign up for Part D during their Initial Enrollment Period, you may qualify for delayed enrollment if you have creditable prescription drug coverage. Otherwise, Medicare can impose a late enrollment penalty. The penalty may not apply if you have prescription drug coverage from an employer, a union, TRICARE (program for active and retired service members), the Indian Health Service (IHS) or an individual healthcare policy.

Make note of these dates for open enrollment: October 15 to December 7 for the annual Open Enrollment Period and January 1 to March 31 for the annual Medicare Advantage Open Enrollment Period. If you lose your insurance coverage or have other qualifying events, apply for a Special Enrollment Period. Contacting a licensed insurance agent may be helpful if you have questions about options based on your circumstances.

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