People With Medicare
Step 4: Which drugs the plans cover
How do I find out which Medicare Prescription Drug Plans cover my drugs?
Each Medicare Prescription Drug Plan will have a list of drugs it covers, called the plan’s formulary. The formulary is important to you because it will tell you three things:
- The names of the drugs the plan covers.
- How much you would pay for each drug. How much you pay depends on what co-pay “tier” the drug is on – see the section on co-pay tiers below.
- If there are limits or restrictions on your ability to get a drug.
The Formulary – List of covered drugs
The drug lists--or formularies--will include both generic and brand name drugs. Some drugs are on every plan’s formulary because Medicare requires it. There are also other drugs that the Medicare law says the plans cannot cover. Medicare must review and approve each plan’s drug list.
If your drug is not on your plan’s list, you will either have to pay full price for the prescription, or switch to a similar drug that the plan does cover. Or you can apply to the plan for an exception to see if your plan will cover the drug. But it’s better for you to start out by picking a plan that has all or most of your drugs on the formulary.
Each plan places the drugs it will pay for in different levels, called tiers. Each tier has its own co-pay or co-insurance amount. Your drugs may be included in all the plans in your area, but they could be listed on different tiers with different co-pay amounts.
Most plans will have three to five tiers. As an example, a plan’s tiers might look like this:
Each plan will encourage you to use the lowest cost drug to treat your medical condition. A drug on a lower tier will cost less than a drug on a higher tier.
NEXT: Picking a plan