each prescription drug plan has a formulary or list of covered drugs

Medicare Part D: What Is a Plan Formulary?

As you may know, Medicare Part D helps make prescription drugs more affordable for beneficiaries who need them. Part D coverage is available through private, Medicare-approved companies. Since prescription drugs are quite costly, it’s critical for people with severe health issues to get this insurance coverage. 

There may be several drug plans available in your area, depending on your state. Before you can pick the right program, there are important terms you should know, including drug tiers and the formulary

Medicare Part D Formulary

Each plan has a list of the drugs it covers called a formulary. The Formulary must include two drugs per category at minimum, although the insurance company can decide the options.  

What Drugs Are Protected?

There are six protected drug classes associated with Medicare Part D, ensuring seniors living with certain disabilities can get the medication they need.

The protected kinds of drugs consist of immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antineoplastics, and antiretrovirals. 

Related Post: What Does Medicare Part D Cover?

Medicare Part D Drug Tiers

Most Part D plans assemble covered drugs into “tiers” by their costs. Generally, the lower tiers have cheaper drugs, and the upper tiers will have more expensive medications.

Drug List (Formulary) Tiers

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Preferred Generic Generic Preferred Brand Non-preferred Drug Specialty Tier

Note: Not all generic drugs are considered low-cost. There are generics in every tier. 

You can review the list for the tier of your generic drug, along with the plan’s summary of benefits, to see what you’ll pay for the medications.

What If a Drug Isn’t on the Formulary?

If your doctor prescribes a drug that isn’t listed in your Part D plan, you’ll need to pay full price for it. However, some beneficiaries may qualify for a formulary exception to avoid paying the total amount. With rising prescription drug costs, we suggest choosing a plan that lists your drugs. 

What Else You Should Know

Your Medicare Part D plan may alter the deductible, premiums, and covered medications every year. Your plan will send you an Annual Notice of Change each September to see the upcoming changes. 

Also, Part D may make changes to the drug formularies throughout the calendar year. Certain changes may involve adding or dropping coverage, depending on the rules. If a change affects one of your prescriptions, you’ll get a written notice one month before the plan implements these changes.

Note: People who already have Medicare are eligible for Part D and should enroll ASAP. You don’t want to face late enrollment fees. 

Related Post: What Is MA-PD?

Need a Medicare Drug Plan? We Can Help

Fussell & Goodyear are experienced Medicare insurance advisors who can help you find the best prescription drug plan for your needs. Whether it be a standalone drug plan or a Medicare Advantage program with built-in Part D coverage (MA-PD), contact us. We have access to the top-rated companies, and we’re eager to assist you.