Each plan includes its own formulary that determines which drugs are covered by the plan and how much the drugs cost based on which tier the drug is classified into.
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The drug formulary of one Medicare plan may differ from another plan’s formulary. Medicare drug formularies can feature both generic and name brand drugs.
Drugs may be added or removed from the market at any time, and therefore drugs may be added or removed from a plan’s formulary. Drugs may also remain for sale on the market but be removed from a plan’s formulary for a variety of reasons.
Some drugs also may be moved to a different cost-sharing tier (see #3 below) or experience a change in plan restrictions (see #7).
Drugs on a Medicare formulary are divided into tiers that determine the cost paid by beneficiaries.
For example, a tier 1 drug might consist of low-cost, generic drugs and require only a small copayment in order to fill a prescription. A tier 4 drug, however, might be a more expensive name brand drug that requires a higher copayment.
The number of drug tiers and the cost breakdown will vary according to each plan.
Beneficiaries reserve the right to request that a Medicare plan cover a particular drug. You can also request to pay a lower amount for a covered drug.
All Medicare formularies generally must include coverage for at least two different drugs within most drug categories, and they must include all available drugs for the following categories:
A Medicare formulary won’t include over-the-counter drugs or weight-loss drugs.
All Medicare plans with prescription drug coverage must make sure that members have access to all medically necessary drugs listed on their formulary.
Some drugs on a Medicare formulary come with certain types of restrictions, such as:
You may be able to find Medicare plan options in your area that feature a drug formulary that fits your prescription drug coverage needs.
To compare plans where you live, call to speak with a licensed insurance agent today.
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Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism. He currently lives in Raleigh, NC.
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