If you are a Medicare beneficiary enrolled in Part D, your benefits include coverage for prescription drugs. However, all Medicare Part D plans have a list of approved drugs referred to as formulary. This means that your Medicare Part D plan will only cover the cost of your prescription drugs if they are included in the formulary of that particular plan.

What is a drug formulary in Medicare?

A drug formulary is a list of the prescription drugs that are covered under your specific Medicare Part D plan. Since Medicare Part D plans are sold by private insurers, each provider has a different formulary. This means that before enrolling in any Medicare Part D plan, you need to check the formulary to ensure that it includes the medications that you need.

All Medicare Part D plans are required to include generic and prescription drugs as well as brand-name prescriptions. This means that regardless of provider, all Part D plans must include categories and classes of drugs that cover all disease states, including:

·        Antipsychotic medications

·        Antidepressants

·        Anticonvulsive medications

·        Immunosuppressant drugs

·        HIV/AIDS medications

·        Anticancer drugs (unless covered by Part B)

·        Vaccines

Note that Part D providers can change their formulary and that some drugs may be dropped or added to the list of what is covered. In case of any changes to your Plan, your provider will notify you in advance.

Restrictions on formulary drugs

It is important to keep in mind that even if a particular drug is included in your Medicare drug formulary, restrictions may apply – for example, to high-cost drugs and drugs that can be potentially abused.

Those restrictions include:

·        Prior authorization: Some prescription drugs require prior authorization before your Medicare Part D plan can cover them. In such cases, your doctor will need to prove that the medication is medically necessary before your plan can cover the cost.

·        Step therapy: For some medications, your Medicare Part D plan may require that you try lower-cost drugs before you can be approved for the prescribed medication.

·        Quantity limits: Your Medicare Part D plan may also have restrictions on the quantity or dosage of a prescribed drug that you can take over a specific period.

It is important to find out what utilization restrictions apply to your Plan’s formulary before signing up to avoid problems accessing your medication, especially if you are chronically ill or on a maintenance schedule.

Medicare drug tiers

Medicare formulary drugs are typically classified into different tiers based on the type of drug and cost.

·        Tier 1: Drugs that are classified as Tier 1 are typically commonly prescribed generic drugs that are low-cost. This tier of drugs will typically have the lowest copayment.

·        Tier 2: This tier usually includes preferred brand name drugs. For this tier, the copayment is usually moderate.

·        Tier 3: Non-preferred brand name drugs fall in this tier, and you will usually pay a high copayment for drugs in this tier.

·        Specialty drugs – This tier usually includes very high-cost brand-name drugs. This tier of drugs usually has the highest copayment.

It is important to note that your plan may have different tier classifications for their approved drugs. You can use Medicare resources to check your preferred plans’ formulary and tier classification. Hellahealth also has a quick and easy plan finder to help you find the right Medicare Part D plan for your needs.