Form
A formulary is a list of prescription drugs, including generic and brand-name drugs, that identifies the drugs that are covered by your Part D or prescription drug plan. Your plan's formulary is classified into several categories known as tiers based on the type of drug and the condition or specialty.
A plan's formulary will generally include both brand name prescription drugs and generic drug coverage, and must include at least two drugs in the most commonly prescribed categories and classes. While plans must cover at least two drugs per drug category, plans may choose which Part D-covered drugs they will offer.
The formulary may not include your specific drug, but in most cases a similar drug should be available. If you or your prescribing doctor believe that none of the drugs on your plan's formulary will work for your condition, you can request an exception from your plan's provider.
A Medicare drug plan may make some changes to your drug list during the year if you follow the guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available.
Plans that offer Medicare drug coverage under Part D can immediately remove drugs from their formularies after they are deemed unsafe by the Food and Drug Administration (FDA) or if their manufacturer removes them from the market. Plans that meet certain requirements can also immediately remove brand-name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand-name drugs by adding new generic drugs. If you are currently taking any of these drugs, you will get information about the specific changes made later.
For other changes related to a drug you are currently taking that will affect you during the year, your plan must take one of these actions:
- Give you written notice at least 30 days before the effective date of the change.
- At the time you request a refill, provide written notice of the change and at least a one-month supply under the same plan rules as before the change.
Note
Starting in 2019, drug plans that offer Medicare drug coverage (Part D) that meet certain requirements can also immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs by adding new generic drugs. If you are taking these drugs, you will receive information about the specific changes to your generic drug coverage later.
You may have to change the drug you are using or pay more for it. You can also ask for an exception. Generally, using drugs on your plan's formulary will save you money, but if you use a drug that is not on your plan's drug list, you will have to pay full price unless you qualify for a formulary exception. All Medicare drug plans have negotiated for lower prices for drugs on their drug lists, so using those drugs will generally save you money.
Generic Drugs
The Food and Drug Administration (FDA) says that generic drugs are copies of brand-name drugs and are the same as brand-name drugs in:
- dosage form
- security
- force
- management path
- quality
- characteristics
- intended use
Generic drugs use the same active ingredients as brand-name prescription drugs. Generic drug manufacturers must prove to the FDA that their product works the same as the brand-name prescription drug. In some cases, there may not be a generic drug that is the same as the brand-name drug you take, but there may be another generic drug that works for you as well. Talk to your doctor or other prescriber about your generic drug coverage.
Levels
To reduce costs, many plans that offer prescription drug coverage place drugs in different "tiers" on their formularies. Each plan may divide its tiers in different ways. Each tier costs a different amount. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
Below is an example of a Medicare drug plan's tiers (your plan's tiers may be different):
- Tier 1 - lowest co-pay: most generic prescription drugs
- Tier 2 - medium co-pay: preferred brand name prescription drugs
- Tier 3 - higher co-payment: non-preferred brand-name prescription drugs
- Specialty tier - higher co-payment: very high cost prescription drugs
In some cases, if your drug is on a higher tier and your prescriber (your doctor or other health care provider who is legally authorized to write prescriptions) thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower coinsurance or copayment for the drug on the higher tier. Plans can change their formularies at any time. Your plan can notify you of any formulary changes that affect the drugs you are taking.
Medicare drug coverage includes drugs for medication-assisted treatment for opioid use disorders. It also covers drugs such as methadone and buprenorphine when prescribed for pain. However, Medicare Part A covers methadone when used to treat an opioid use disorder as an inpatient in a hospital, and Part B now covers methadone when you receive it through an opioid treatment program. Contact the plan to obtain your current formulary or visit the plan's website.
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