Decoding your Prescription Drug Formulary

It would be a much easier for all of us if all the Medicare Prescription Drug plans and Medicare Advantage plans covered all drugs at the same cost. Unfortunately, it is not that easy.

Each Prescription Drug plan and Medicare Advantage plan determines which specific drugs it will cover. Their list of covered drugs is called their formulary and every plan’s formulary is unique to that plan. Formularies include both brand-name and generic drugs and include at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need.

What is a tiered formulary?

Every plan creates its own formulary structure, decides which drugs it will cover and determines which category or tier a drug is in. There may be three, four or five tiers in a plan. Tier 1 drugs generally cost the least. Higher tiers may require approval from your insurance company and may cost more. 

One plan may cover a drug that is not covered by a different plan. Or, the same drug may be on tier 2 in one plan’s formulary and on tier 3 in a different plan’s formulary.

Each plan determines the co-pay or co-insurance (your share of the cost) for its tiers. How much your medication costs depends on the plan and the tier your drug is in.

If this is not confusing enough, your plan is permitted to change its formulary. It may add or remove a drug from its formulary or move a drug into a different tier. Usually, plans must inform members in advance if they are removing a drug.

It is important for you to make sure your prescriptions are covered at a cost you can afford before you enroll in a Medicare Advantage plan or a Medicare Prescription Drug plan. At Mutsko Insurance Services, we help our clients with this research, comparing  prescription coverage and costs to help them find the right plan for them. It is all part of the services we provide – and there is never any cost for this service.

If you would like to learn more, please call us today to set up an appointment at 440-255-5700 or email me at Lmutsko@mutskoinsurance.com.