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November 23, 2021

Medicare Prescription Drug Formularies

How much you pay for your medication will vary, even if you have Medicare Part D coverage. That’s because every pill has a different value and use. How insurance companies pay for different drugs will likewise differ. This likely comes from the way Medicare’s prescription formulary pays. How does the formulary system work? 

Depending on the medication you need, you might find the formulary charges you more or less for each drug. Work with your physician to determine the appropriate drugs and costs for you. 

Medicare Part D Coverage 

Medicare Part D is Medicare insurance for your prescription drugs. Many drugs can cost hundreds of dollars without insurance. Therefore, having this coverage is critical for countless Americans. Getting Medicare Part D involves taking special steps beyond enrolling in Original Medicare. 

Original Medicare only contains Medicare Part A and/or Medicare Part B. Part A will pay for things like hospitalizations, while Part B will pay for care like doctor’s office visits. Neither part of Original coverage will pay for most standard prescription needs. Therefore, for this coverage, most people turn to Medicare Part D. Nevertheless, even with coverage, the cost for your prescriptions might still vary. 
Medicare on Chalk board
The Part D Formulary 

Medicare Part D is actually a marketplace of private plans offered by major insurers. These plans conform to certain federally-mandated guidelines. Yet, Part D providers often have leeway to determine what you will pay for prescriptions.  

Most do this by developing a formulary. Under a formulary, Part D providers list what drugs they will cover under your plan. They will often cover many different drugs, from prescription generics to name-brand medication. Often, you will have at least one choice of similar drugs to make selecting a medication easier on you. 

To simplify drug pricing, formularies usually divide drugs into Tiers. Most Part D plans contain four tiers (Levels 1-3 and a Specialty tier), though again, plans differ. Usually, the drugs in the lowest tiers will have the lowest costs. Specialty prescriptions, and some brand-name drugs often occupy higher tiers and cost more. Keep in mind, at times you can qualify for tier exceptions based on your medical needs. Therefore, you might be able to get a higher-tiered drug at a lower cost. 

So, once you get Medicare Part D, talk to your doctor about the best way to get the most affordable drugs. Your physician will likely understand the way the formulary works. They can help you determine the best cost-treatment balance for your medication. 

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