tiers are how Medicare Part D plans are organized by price

What Are the Medicare Part D tiers?

Medicare Part D is the prescription drug coverage available to Medicare beneficiaries that have already enrolled for Medicare Part A and Part B (Original Medicare). Medicare Part D has two prescription drugs in the generally prescribed categories. Medicare Advantage (Medicare Part C) plans with prescription drug coverage and standalone Medicare Part D prescription drug plans all have lists of prescription drugs they cover and are known as “Formularies.” Generally, medications in the formulary are sorted into separate tiers depending on the drug costs.

Drug Formulary Coverage

Each drug formulary is required by Medicare to include at least 2 medications in the commonly prescribed drug categories, but each plan’s formulary may include different medications. All prescription drug plans are expected to cover certain medications in these categories:

  • Immunosuppressants
  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • Antiretrovirals
  • Anticancer

However, these plans don’t cover every possible medication. For instance, they don’t cover drugs for weight loss/gain, cosmetics, vitamins, and over-the-counter medications. Before choosing a Part D plan, you may want to confirm that your current drugs are included in the prescription drug plan’s formulary. Also, you may want to understand the tiers in which your prescription drugs are located and which local pharmacies are in the Medicare drug plan’s network.

What Are the Medicare Part D Tiers?

Tiers are the ways in which prescription drug plans are organized by price. What you pay for a medication mostly depends on the tier your drug is in. A Medicare Part D formulary is usually categorized into five tiers, which include:

  • Tier 1 (Preferred Generic): this formulary tier has the lowest cost share
  • Tier 2 (Non-preferred generic drugs): this formulary tier has a higher cost share than the formulary tier 1 drug.
  • Tier 3 (Preferred brand-name drugs): this formulary tier is higher in cost than formulary tier 2.
  • Tier 4 (Non-preferred brand-name drugs): this formulary tier is usually higher in cost than formulary tier 3
  • Tier 5 (Specialty drugs): this formulary tier is the most expensive.

To get the most out of your coverage, make a note of where your medications fall within the Medicare Part D tiers and ask your prescriber or doctor for advice. If your doctor feels that you need a certain drug from the pricier formulary tier, you must be required to file for an exception and request from your provider to consider giving you lower-cost sharing for the particular medication.

If you need a prescription drug that is not available in your formulary, you can ask for an exception. However, your prescriber or doctor will have to provide a supporting statement that explains the medical reason why it is required.

Formulary Changes

Medicare Part D prescription drug plan providers are allowed to change their drug formulary, but their members must be notified if the drug they are taking will be affected. However, if the medication is taken off the market by the FDA, you may not be notified in advance, although your plan may contact you.

Do you have any more questions about Medicare Part D and if your prescriptions will be covered? Don’t hesitate to contact Generations Insurance today.