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Do all Medicare plans offering prescription drug coverage cover the same medications?

October 6, 2016

No. The list of covered prescription drugs (also known as a formulary) can vary from plan to plan. However, all Medicare plans with prescription drug coverage are required to cover at least two medications in each therapeutic category/class approved by Medicare. Moreover, Medicare plans with prescription drug coverage must cover the majority of prescription drugs in the following therapeutic categories: antidepressants, antipsychotics, anticonvulsants, antiretroviral (AIDS treatment), immunosuppressants and anticancer agents. Despite the broad spectrum of covered prescription drug categories, not every prescription drug will be covered by a Medicare plan with prescription drug coverage.

Whether you choose a Medicare Advantage Prescription Drug plan or a stand-alone Part D Prescription Drug Plan, you will want to select a plan available where you live that best meets your personal prescription needs and financial circumstances. Many Medicare plans offering Part D prescription drug coverage arrange their formularies, or lists of covered medications, into tiers.

The out-of-pocket expenses or copayment you will pay for the prescription drugs depends on which tier the prescription drug is assigned. Many formularies are organized into five tiers, with preferred generic medications assigned to the lowest, and least expensive tier and specialized medications assigned to the highest, and most expensive tier.

The plan’s formulary may change at any time. However, you will receive notice from your plan if a formulary change affects you. Furthermore, every Medicare plan with prescription drug coverage must have a process for members and their doctors to request exceptions to the plan’s formulary if a non-covered medication is medically necessary or if the individual requires an exception to another aspect of the formulary, such as a quantity limit.

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