What is a Part D Formulary?

part D
Original Medicare doesn’t cover most prescription drugs Medicare beneficiaries take at home, which is why many people look to Medicare Part D prescription drug coverage. This part of Medicare is administered through private health insurance companies. You can either get Medicare prescription drug coverage through a Medicare Part C plan with drug coverage or a standalone Part D plan that works with Original Medicare.
Though all Medicare Part D plans are required to comply with the same Medicare guidelines, there are differences in coverage and cost. So, it is best to do some research before making a decision. The first step is to look at each Medicare Part D formulary.

What is a Part D Formulary?

This is a list of prescription drugs that a Medicare Part D plan covers. Most people simply refer to the formulary as a drug list. Due to the fact that Medicare Part D prescription drug plans are provided by private insurers, each provider can decide which medication to cover. However, a formulary is required to meet the minimum standards and requirements of prescription drug coverage.
Since the list of drugs covered can vary from one plan to the other, it is vital to review each prescription plan’s formulary to make sure your drug is included at a price that you can afford. Most formularies are organized into different tiers, with the lowest tier being the cheapest and comprised of medications that require the lowest payment. Formularies include both brand-name and generic drugs.
To provide support to Medicare beneficiaries with several health conditions, the drug list is structured to include at least 2 medications in each category. In the case the list of drugs covered by the plan doesn’t include your specific medication, it will typically include a drug that is comparable. However, you may have to talk to your doctor in this case, and you might be advised to submit an exception request to your Medicare Part D plan provider.

Prescription Drugs Covered Under All Part D Formularies

According to CMS, the prescription drugs listed below must be covered. Part D formularies are also required to cover all commercially available vaccines. Medicare Part D prescription drug plans must cover considerably all of the following:
  • Anticancer
  • Antidepressants
  • Anticonvulsants
  • Antiretrovirals
  • Antipsychotics
  • Immunosuppressants

Prescription Drugs Not Covered Under Part D Formularies

While each plan has a specific formulary, there are specific drugs that Part D plans will not cover:
  • Over-the-counter drugs
  • Fertility drugs
  • Weight loss or weight gain drugs
  • Drugs for sexual or erectile dysfunction
  • Drugs for cosmetic or hair growth purposes
In addition, Medicare Part D plans are not required to cover drugs that are already covered by Original Medicare and medications not approved by the FDA.
For more information on Medicare Part D formularies, please contact Proinsurance Hawaii today!