While the federal government designed the model for Medicare Part D plans, every plan has its own list of covered drugs. It depends on the pharmaceutical company it is associated with. This list is called a “formulary”, and may have quantity limits, pre-authorizations or step therapy associated with a drug. Medicare designed these plans to have an annual deductible, an initial coverage amount, a gap or “donut hole” and catastrophic coverage. Some plans conform almost exactly to the Medicare design and others offer more or extended benefits. All plans must be approved by the Centers for Medicare and Medicaid Services (CMS).
Medicare drug plans separate drugs into different tiers. Most plans have 4 tiers, some have 5, with tier 1 used for generic drugs at the lowest cost. There are also tiers for Brand name, Non-preferred Brand name and Specialty Drugs that are high cost or are specialized for a certain condition. Always check to make sure that the drugs that you currently take are on the formulary of the plan you are thinking of choosing, and what tier they are in to be sure of the costs you will pay.
A formulary is required to have at least 2 drugs from each therapeutic class in a category. Formularies must cover nearly all drugs in six classes: anticancer, antidepressants, anticonvulsants, antiretroviral, antipsychotics and immunosuppresant drugs. Some drugs such as tranquilizers, sedatives and over-the-counter medications aren’t covered at all. Here again, check with the plan specific to make sure that your drugs are covered under a plan you’re considering.
Plans are allowed to alter their formularies throughout the year. In general, if a change affects a drug you are using, the plan must inform you of the change at least 60 days in advance.
If you would like to find out which of your medications are included in which Medicare Prescription Drug plans, give us a call at 800-535-3304. One of our Medicare insurance specialist would be happy to assist.