Medicare Advantage Plans

Starting At $0/ Month

Just give us a little information,
and find out if you have $0 Premium Plans in your area.

Prescription Drug Coverage Formulary

Medicare prescription drug coverage ensures you get the medications you need to stay healthy and strong. But whether you receive benefits through a standalone Part D plan or Medicare Advantage, understanding drug coverage can be complicated. With formularies and tiers, there’s much to know. To help you make sense of prescription drug coverage, here’s a quick summary of a formulary and how it works.

Formularies and Tiers

Each Medicare prescription drug plan has its own formulary or list of medications that are covered. The formulary organizes both generic and brand-name drugs into different classes or tiers that are grouped by cost. Generally, drugs in lower tiers cost less than those in higher tiers. For example, a brand-name drug to treat high blood pressure may be in Tier 3, while the generic version of the same drug might be available in Tier 1. Most prescription drug plans offer 4 tiers, and some offer 5:

Tier 1: Most generic prescription drugs, lowest copayment

Tier 2: Preferred, brand-name prescription drugs, medium copayment

Tier 3: Non-preferred brand-name prescription drugs, higher copayment

Tier 4: Specialty, unique, costly prescription drugs, highest copayment

Formularies change from year to year and you must review your Medicare Annual Notice of Change (ANOC) to make sure any medications you take are still covered. However, if your plan makes changes that impact you, they are required to let you know 60 days before the change takes effect.

Saving Money Using Formularies

Medicare drug plans negotiate pricing with drug companies, securing lower prices for medications than you could get yourself. Because of this, using drugs listed in your plan’s formulary may cost you less than using drugs outside of the formulary. Also, choose the generic version of drugs whenever possible to save even more. Generic drugs are essentially copies of brand-name drugs. How they are administered, dosage, safety, and strength are the same with both. Generic drugs use the same active ingredients as brand-name drugs and are used safely as a reliable alternative to more costly versions. The majority of prescriptions filled today use generic drugs. 

When Your Drug Is Not on the Formulary

In the event a drug you need is not covered by your plan’s formulary, you may be able to get a formulary exception—a type of Medicare prescription drug coverage determination where your plan decides to cover a drug that’s not on the list. There are exceptions to tiers and formularies, but each requires a request from you or your provider as well as a supporting statement from your doctor explaining the medical reason behind the exception.



Get a Free Quote







Costs associated with using formularies: https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf page 2, 3

Formulary and tiers: https://www.medicare.gov/part-d/coverage/part-d-coverage.html


Leave a Reply

Your email address will not be published. Required fields are marked *

Testimonial Doug really made me feel at ease with my decision to keep my doctors. Thank you for making this an easy transition. Arthur Brown, Albuquerque
Testimonial Marc was so patient in explaining the benefits to me. After he left I felt as if I understood my benefits better than I ever had in the past. Thank you for having him come out to my house to meet with me. Cecilia Garcia, Albuquerque
Testimonial Beverly, Bless your heart for helping me during this transition. I was scared and confused and didn’t know who to turn to. After coming to speak with you I felt at ease. I am glad that I am all taken care of and don’t have to worry about losing my doctor. Teresa Duran, Albuquerque

Latest News

Read all the news

Medicare Part A and B Coverage

Like most seniors, there’s a good chance you’ve heard of Medicare – you may even know that it’s a federally…
Read more

Medicare Supplement – Coverage for Out-of-Pocket Expenses

Medicare Supplement insurance (also called Medigap) offers seniors coverage for out-of-pocket expenses associated with Medicare like copays and coinsurance, and…
Read more

Is Medicare Advantage a Good Deal?

Medicare Advantage (MA or Part C), is a popular alternative to traditional Medicare. Since 2010, enrollment increased by 71 percent,…
Read more

Medicare Part D Prescription Coverage

Original Medicare (Part A and Part B) does not include benefits for prescription drugs. While you are not required to…
Read more

Medicare Enrollment Checklist

9 to 12 months before you turn 65 Confirm that you are eligible to receive Medicare benefits by calling the Social Security…
Read more