Each insurance plan has a drug formulary — a tiered list of generic and brand-name medications your plan covers. Making use of your Medicare prescription drug formulary is a smart way to lower your prescription drug costs and get the medication you need.

Prescription coverage formularies are common across insurance plans, and most change at the start of each calendar year. If you’re not used to using them, they can be difficult to find and understand. Here are some quick tips for understanding your plan’s drug formulary.

Prescription drug formulary tiers explained

Drug formularies (also called drug lists or drug guides) are organized by tiers: categories of covered drugs based on type, purpose, and cost. While plans differ across providers, many formularies have anywhere from three to five or more tiers, ranging from low-cost generic drugs to specialty drugs with high out-of-pocket costs. 

Here’s an example of how a Medicare prescription drug formulary could be structured:

• Tier 1: Preferred generic prescription drugs with low or no copay
• Tier 2: Preferred brand-name prescription drugs with medium copay
• Tier 3: Non-preferred, specialty brand-name prescription drugs with high copay

Some plans may have additional categories for covered drugs or divide their tiers differently. If a drug you need isn’t included in the formulary, you may have to pay full price for it.

Which drugs are included in the formulary tiers?

While the specific drugs covered vary, each plan’s formulary has to include at least two drugs for each of the most commonly prescribed categories, including antibacterials, barbiturates, and cough suppressants. 

Additionally, Medicare Part D plans are required to include most drugs within six protected classes of medications:

• Immunosuppressants for organ transplants
• Antidepressants
• Antipsychotics
• Anticonvulsants for seizure disorders
• HIV/AIDS drugs (antiretrovirals)
• Anticancer drugs not covered by Part B

Part D drug formularies are also required to cover all medically necessary vaccines that are commercially available.

How to locate your Part D or Medicare Advantage formulary

Your Part D or Medicare Advantage drug formulary is included in your plan documentation or disclosure materials, which your provider mails to you after you enroll. Some plans also have online portals that allow you to access your plan’s drug list. If you can’t find what you’re looking for, you can call the number on your insurance card to get more information.

Alternatively, if you’re looking to compare Part D formularies to learn which drugs are covered by which plans, you can use CMS’s prescription drug plan resource to find what you need. You can also log in to Medicare’s online portal (once you have Part A and/or Part B) to compare formularies for Part D plans available in your area.

How to stay informed of changes before the Annual Enrollment Period

The Annual Enrollment Period (AEP) is one of the only times during the year you can make changes to your plan. This is why it’s important to keep track of changes to your plan’s drug lists throughout the year, especially if you have a change in medication.

The best way to stay informed of changes before the AEP is to keep an eye on correspondence from your plan provider. Specifically, look out for your Annual Notice of Change (ANOC) in September, as it outlines ways your plan will change come January. If your plan changes during the year (e.g., your drug is discontinued, no longer available on your plan, or becomes more expensive), providers are required to give you written notice about the changes and how they affect you. 

What to do if your drug isn’t covered anymore

There are many reasons a drug’s availability may change during the year. Sometimes, the drug is discontinued by the manufacturer or recalled by the FDA. Other times, your plan simply no longer offers it. Instead of going without medication, consider one of the following courses of action:

• Use an alternative in the formulary: Plans are required to provide at least two “chemically different” drugs under each category, so talk with your doctor and check your formulary for alternatives.
• Request an exception: If your drug is medically necessary but not available (or has dosage limits), work with your doctor to request a formulary exception from your plan provider. 
• File an appeal: You can also ask your doctor or representative to file an appeal if your exception is denied. 
• Explore other plans: If none of the above options work, you can always look into other plans. You can even search for plans that cover your specific medications or compare drug coverage options across plans.

All told, your drug formulary is an essential part of keeping medication costs down. You can access yours through your provider’s portal, using CMS resources, or via notices from your plan. If your formulary changes and you need support navigating Medicare Advantage or Part D, or if you’re comparing plans and considering enrolling, reach out to SmartMatch — we’re here to help!

*Disclaimer:

The information provided in this blog post is intended for general informational purposes only and does not constitute medical advice. It is not a substitute for professional medical consultation or treatment. Always consult with a qualified healthcare provider for any questions you may have regarding a medical condition.

SmartMatch does not endorse or recommend any specific products, treatments, or procedures mentioned in this article. Reliance on any information provided in this blog post is solely at your own risk. We encourage you to discuss any health concerns or questions with your doctor before making any decisions about your health or treatment.