Formulating an Understanding of Formularies

  admin       Jun 02, 2023

Formulating an Understanding of Formularies

The process of comparing Medicare Part D prescription drug plans can be stressful. Luckily, the U.S. Centers for Medicare & Medicaid Services has created a Medicare Plan Finder Tool that can help you find plans available in your service area and compare plan details, such as formularies and costs, side by side.

Each Medicare Part D plan has its own unique list of preferred drugs called a formulary. Medicare Part D formulary can include both name-brand and generic medications. Carriers can choose which specific drugs each of their plans will and will not cover.

So, what is covered in a Medicare Part D formulary?

Federal law requires every Medicare Part D plan to cover at least two drugs in each class of drug category on their formulary. Most plans will cover more than two drugs in each class. This means that even if your current medication is not on the formulary, it is highly likely that a comparable medication is covered.

All Medicare Part D plans are also required to cover nearly all drugs within six drug classes on their formulary:

1. Antipsychotics
2. Antidepressants
3. Anticonvulsants
4. Immunosuppressants
5. Anticancer drugs (unless covered by Medicare Part B)
6. HIV/AIDS drugs

Additionally, between your Medicare Part B coverage and whichever Part D plan you choose, all commercially available vaccines will be covered, including flu, pneumonia, and shingles.

You may have to jump through a few hoops.

To keep your copays low, many plans organize the prescription drugs on their formulary into Tiers. Tier 1 will usually include most generic medications at the lowest cost to you. Tiers 2-5, which may include a “specialty” tier, will include preferred and non-preferred brand name prescriptions at higher copays.

Medicare imposes various utilization management rules to ensure that medications are being used properly. These rules include:

• Prior Authorization – requires the prescriber to submit a request to the plan to cover a specific drug because it is medically necessary.
• Quantity Limits – plans may limit the quantity of medication they will cover in a certain time period.
• Step Therapy – plans may require you to try an alternative, lower-cost medication before approving a more expensive option.

What if your medication is not covered by your plan’s formulary?

Generally, all Medicare Part D plans have a list of medications that they are not allowed to cover or may offer as an additional premium benefit. These include medications for weight management, fertility, erectile dysfunction, and non-prescription drugs, vitamins, and minerals. If your plan does not cover the medication, you will have to pay out-of-pocket.

If your doctor prescribes you a medication not covered by your plan, you still have options. If the utilization management rules are not effective for your treatment plan and your doctor feels that a drug not covered by your plan is medically necessary, they can file for an exception, sometimes referred to as a coverage determination. Your plan or pharmacy can assist you in obtaining the paperwork to file an exception.

Medicare Part D formularies are subject to change.

You should also be aware that Medicare Part D plans can change their formulary during the year if they follow certain guidelines.

Medications may be immediately removed from a plan’s formulary if they are recalled from the market by the Food and Drug Administration because they are deemed unsafe, or if a drug manufacturer discontinues production of the drug.

The introduction of a new generic medication can also impact your formulary throughout the year. New generics may replace existing brand name medications, or the brand name medications may be pushed up to a higher tier.

If your plan decides to make any other formulary changes throughout the year, they are required to notify you at least 30 days before the change happens.

At the beginning of this article, we mentioned the Medicare Plan Finder Tool offered by the U.S. Centers for Medicare & Medicaid Services. Though this tool is designed to help consumers make educated decisions about their Medicare benefits, issues with the Plan Finder tool have been reported.

To make sure you have the most complete, up-to-date Medicare Part D formulary information, schedule a time to meet with a Wefel’s Group team member. Our advisors can help ensure you make the best plan decision to fit your needs.