If you rely on medications, it’s important to review each Part D plan’s formulary, to confirm the prescriptions you need are listed.
Formulary
Each plan has its list of covered prescription drugs, called a formulary. Medications are classified into tiers, the lowest costing less than those in higher tiers. Be sure to check that your medications are listed. If you don’t see yours listed, search for another plan. These lists often change yearly, meaning your medications may no longer be available next year. Prescription drugs change tiers or move between classifications. Even if you are happy with your coverage, you must review the Annual Notice of Change for the upcoming year to avoid being surprised at the pharmacy.
Tier 1 – Generic, lowest copayment
Tier 2 – Preferred, brand-name, medium copayment
Tier 3 – Non-preferred brand name, higher copayment
Tier 4 – Specialty, highest copayment
Over-the-Counter
It’s important to know which medications will be covered under the plan, and which are not. Part D does not provide coverage for over-the-counter medications, including cough and cold medicine, and vitamins. Medicare covers some medications that Part D does not. For instance, vaccines, cancer drugs, and certain injectable drugs are covered under Part B if you receive them in an outpatient setting, like your doctor’s office.
Not Covered
In the event your medications are not covered under the plan, there are things you can do.
Substitutes
In many cases, formularies do not cover brand-name drugs but do offer coverage for generic, or low-cost alternatives. Ask your doctor if there is a substitute for the medication that’s not covered under your plan.
Exception
Medicare is open to listening to your doctor if he or she believes that a specific drug is the only medication that will help your condition. An exception may be granted if your doctor and Medicare agree that it is medically necessary. You also have the right to file an appeal should Medicare deny your request.
Change Coverage
Each plan is different, and your prescriptions may be covered under a different plan’s formulary. If your current coverage no longer covers your medication, and you find a new plan that does, you can change during Annual Enrollment (October 15 – December 7) each year.
References:
https://www.medicare.gov/part-d/coverage/part-d-coverage.html
https://www.medicare.gov/part-d/coverage/rules/drug-plan-coverage-rules.html
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