Medicare Part D Prescription Drug Plan
- Medicare Part D plans covers a wide range of prescription drugs.
- Medicare Part D plans including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDs.
- Medicare Part D plans come with a list of covered drugs (formulary) specific to the plan.
- Medicare Advantage and Medicare Part D plans place drugs into different levels called “tiers” on their formulary. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
- Tier 1—lowest copayment: most generic prescription drugs
- Tier 2—medium copayment: preferred, brand-name prescription drugs
- Tier 3—high copayment: brand-name prescription drugs
- Tier 4—higher copayment: non-preferred, brand-name prescription drugs
- Tier 5—highest copayment: Specialty tier highest cost prescription drugs
Medicare Part D Formulary Exception
- Medicare drug plans may have these coverage rules:
- Opioid pain medication safety checks
- Prior Authorization
- Quantity limits
- Step therapy
- Part D vaccine coverage
- Drugs you get in hospital outpatient settings
- If you or your prescriber believe that one of these coverage rules should be waived, you can ask your plan for an Exception.
- Your prescriber (doctor) feels you need a higher Tier drug instead of a similar lower Tier drug, your prescriber may ask your plan for a Formulary Exception. Tier reduction to lower your co-pay may also come into play.