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Understanding the Medicare Part D Formulary

The Medicare Part D formulary is a list of drugs that have coverage under your policy. The formulary must include at least two drugs per category, and the insurance company can choose the options.

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But what exactly is a drug formulary? What happens if your medication isn’t part of this formulary? We’re here to address all those questions and so much more!

What is the Medicare Part D Formulary?

The Medicare Part D Formulary is a list of covered drugs on your prescription drug plan. The plan can change the formulary anytime, but they must notify you. Each plan has a different list of drugs.

You’ll want to find the formulary that fits with the medications you take. But, it can be hard to predict next year’s prescriptions. So, what do you do when a new prescription isn’t on the formulary? We will get to that later, but first, let’s go over some important details.

Medicare Part D drug plan formularies have 4 tier options.

Do all Drug Plans Have a Formulary?

Yes, all drug plans have a formulary. Plans will include generic and brand-name prescriptions.

Plans must cover the six protected classes. But, every formulary may not contain your medication.

Every insurance plan has its drug formularies. Each medication must adhere to the Food and Drug Administration’s (FDA) regulations.

What Happens if a Drug is Not on the Formulary for a Medicare Part D Provider?

If your drug isn’t on the formulary, you’ll likely pay the full price. Of course, you can request a formulary exception or file an appeal.

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How Can I Appeal a Drug on the Part D Formulary?

You can file an appeal when you disagree with the decision made by the insurance company. So, if the plan denies a drug claim but you believe it should have coverage, you can file an appeal. You may need supporting documents to show necessity, prior authorization, or step therapy requirements have been met.

How Can I Get a Drug on the Part D Formulary?

If the medication you need is not on your Part D formulary, you seek a formulary exception. A Formulary Exception is a form of a request to determine coverage. By obtaining an exception, you may be able to get a drug that’s not on your plan’s formulary or ask your plan to bypass step therapy or prior authorizations.

To request a Formulary Exception, your physician will complete an Exception form on your behalf and submit it to your health insurance policy.

What is a Tiering Exception?

A tiering exception is a request to lower your cost-sharing. To qualify for a tiering exception, the doctor must prove the preferred drug option wouldn’t be as effective as the prescription, or the document would show the preferred drug doesn’t work for you; in some cases, both. Talking to your doctor is the best way to determine if a tiering exception is right for you.

How to Petition for a Part D Formulary Exception?

If your prescription coverage determination isn’t acceptable, your decision will provide all the necessary information to submit a redetermination request with your plan.

What Situations Would Warrant an Exception?

Several common occurrences could warrant your request for a tiered or formulary exception. If these things occur, an exception could be in your future.

You may qualify for a formulary exception if:

  • A doctor prescribes a medication that’s medically necessary but not on the plan’s formulary.
  • You’re using a drug that moves from the preferred to the non-preferred tier, and you’re unable to use other medications.
  • A doctor prescribes a prescription, but it requires prior authorization or step therapy; however, you don’t feel you can meet the requirements.
  • Your plan removes your medication from the formulary, and there aren’t other drugs you can use

Keep in mind, just because one of these is valid doesn’t mean you’re guaranteed a formulary exception.

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When Is A Formulary Exception Likely to Be Approved?

Exceptions are more likely to see approval when the requested medication is medically necessary for you. Your doctor must submit a statement to your plan supporting the exception request.

If you’re seeking a tiering exception, your doctor’s report must state that the preferred medications would adversely affect you. If you’re trying to obtain a formulary exception, your doctor’s statement must indicate that the non-formulary drug is necessary.

The report must also note that other medications in different tiers would not be as effective or could cause severe adverse reactions.

FAQs

How often does Medicare update the formulary list?
Companies may make changes to drug formularies throughout the year. Your plan will send you an Annual Notice of Change. If you choose to switch Part D plans because of impending changes, you can do so during the Annual Enrollment Period.
What if my medication is not on the formulary list for Medicare Part D?
If your doctor prescribes a medication that isn’t on your insurance plan’s drug list, you’ll pay the entirety of the cost of the prescription rather than just a copayment. Unless you qualify for a formulary exception.
What if I buy a Part D plan and later I'm prescribed a med not in the formulary?
You may pay for the medication yourself. But, sometimes, you can find a manufacturer coupon to help cover the cost. Or, you can file an appeal or request a formulary exception. Then, during AEP, you can change your Part D plan.
What drugs are not covered by Medicare Part D?
Medicare doesn’t cover medications for weight loss or cosmetic purposes. Also, over-the-counter drugs don’t have coverage either.
Do formulary exceptions count towards the donut hole?
When you receive a formulary exception, the drug in question will count toward your true out-of-pocket costs (TrOOP). Therefore, you may end up in the Part D coverage gap (donut hole) faster. Yet, it also counts toward getting you out of the donut hole and entering the catastrophic coverage phase.

How to Know What Medications are in a Medicare Part D Formulary

If you have a health insurance agent, they can assist in finding your plan’s formulary list. You can check insurance carrier websites to view the drug formularies they offer.

Those with Medicare are eligible for a drug plan and should enroll as soon as possible. If you’d like more information on Part D formularies, call our team of agents today!

No time to call right now? Just fill out an online rate form and begin the process of comparing plan options now!

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Medicare Insurance Agent, she brings a wealth of knowledge and expertise to her writing.

10 thoughts on "Understanding the Medicare Part D Formulary"

    1. Hi Karla, unfortunately no Medicare Part D plan allows you to combine coverage with a GoodRx discount. You will have to use one or the other when you pick up your medications at the pharmacy.

    1. Hello, Gaytha. I am seeing Xifaxan 550mg tablets covered on the formulary for all SilverScript Medicare Part D plans as a tier 5 Specialty drug. As a specialty drug, this means you will pay 25-33% of the retail cost of the drug (depending on the SilverScript plan you are enrolled in).

  1. I would like to know how I can lower the cost of deductible or get an exception from paying it and lowering the cost for Imbruvica which is a Tier 5 drug with Envision part D . For Envision part d there are two deductibles that equal 7,000 before you can get the drug at the after deductible price which is also high. There is no other drug that is generic or otherwise that I can use for treatment at this time. Help

    1. Hi Michele, you will need to speak with your prescription drug carrier about reducing the cost of your drug or file a tier exception for the drug. Additinally, there are discount programs like GoodRx and Cost Plus Drugs that may be able to lower your cost if the drug is available through those platforms.

  2. Received Silver Script 2021 Annual Notice of Changes. Says formulary changes can be found electronically — they can’t. I’m a physician and have tried for 3 frustrating hours to no avail. Nowhere can I find any reference to the above.

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