What is a Formulary?

A plan’s list of drugs is known as a “formulary”. Most drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of drugs that are covered, called a formulary. All plans must cover a broad range of prescription drugs that folks with Medicare take. This includes most drugs in certain protected classes as an example; cancer or perhaps HIV/AIDS. Many plans place drugs into levels that are different, called “tiers,” on their formularies. Drugs in each tier have a different cost. For instance, a drug in a lower tier will generally cost you less than a drug in a higher tier.

This year (2021) if you take insulin, you might be able to get Medicare Prescription Drug Coverage Plan D that will offer drastic savings on insulin. Most carriers call this an Insulin Senior Savings Plan (ISSP).

Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes no less than two drugs in the most prescribed classes and categories. It will help make certain that folks with various health conditions are able to get the prescription drugs they need. All Medicare drug plans generally must cover no less than two drugs per drug category, but plans are able to choose which drugs covered by Part D they’ll offer.

The formulary might not include your specific drug. Nevertheless, in most cases, a similar drug should be available. When you or perhaps the doctor of yours or any other health care provider who is legally allowed to write prescriptions believes none of the drugs on your plan’s formulary will work for the condition of yours, you are able to ask for an exception.

A Medicare drug plan can make several changes to its drug list during the year. It must follow guidelines set by Medicare. The plan of yours could change its drug list during the year because drug therapies change, new drugs are released, or perhaps new medical info becomes available.

Plans offering Medicare drug coverage under Part D may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting certain requirements also can 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 when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterward.

For other changes involving a drug, you’re currently taking that will affect you during the year, your plan must do one of these:

  • Give you written notice at least 30 days before the date the change becomes effective.

  • At the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change.

You may need to change the drug you use or pay more for it. You can also ask for an exception. Generally, using drugs on your plan’s formulary will save you money. If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generic drugs instead of brand-name drugs may save you money.