What is a medicare formulary and why is it important?

HOW CAN I FIND DRUGS COVERED IN A PART D PLAN’S FORMULARY? Most plans list formularies on their websites under plan documents. You also can request a plan’s formulary. In addition to noting

every drug your plan covers, you can see if the plan has any drug restrictions, such as prior authorization or step therapy requirements. In that case, you may need special permission before

your plan will cover the drug or dosage prescribed, even though it’s on the plan’s formulary. You’ll want to find out how much the plan charges in copayments, which is a fixed dollar amount

you pay for each prescription, or coinsurance, the percentage of your medication’s total cost that you pay. Most Part D plans have four or five pricing tiers, each with different levels of

copayments or coinsurance. Higher tiers generally come with larger out-of-pocket costs. TIER 1: Preferred generic drugs TIER 2: Nonpreferred generic drugs TIER 3: Preferred brand-name drugs

TIER 4: Nonpreferred brand-name drugs TIER 5: Specialty drugs The specific drugs in each tier can vary from plan to plan, even if all the plans cover the drug in their formularies. You can

see which Part D plans in your area cover your drugs, what coverage restrictions they have and how much they charge in coinsurance or copayments by comparing Part D plans in Medicare’s Plan

Finder. WHEN CAN MY PART D PLAN CHANGE ITS FORMULARY? The most common time for a Part D plan to change its formulary is at the beginning of the calendar year. But the plans are allowed to

make changes more often. For any changes taking effect Jan. 1, including formulary, premiums, deductibles and copayments, your plan must notify you the prior September. That’s when you’ll

receive an Annual Notice of Change with any adjustment planned for the following year and the new formulary. You can make changes to your coverage and review other options during the annual

open enrollment period (Oct. 15 to Dec. 7). If you switch to a different Part D plan, your new coverage will begin Jan. 1. If you’re eligible for the Extra Help program, which helps people

with low incomes pay Part D expenses, you can switch Part D plans as often as once every quarter. Your plan must inform you of any formulary changes involving a drug you’re now taking. It

must either send written notice of the change at least 30 days before the change takes effect, or send written notice at the time you request a refill and provide a 30-day supply of the drug

under the same terms. This notice will list alternative drugs in the same therapeutic category or class of your current medications, as well as explain the steps needed to ask for an

exception to the new policy. In some cases, the plan must allow you to continue to take your present drug for the rest of the year, if medically necessary, regardless of the formulary

change. If your drug is removed from the market because the FDA has deemed it unsafe, your plan must notify you as soon as possible. Work with your doctor to determine an alternative

medication that fits with your plan.