How to Check if Your Medication is Covered by Medicare

What is a Medicare Formulary?

When navigating the world of Medicare, one of the most critical terms you'll encounter is "formulary." Simply put, a formulary is a list of prescription drugs covered by a specific insurance plan. Every Medicare Part D (prescription drug plan) and Medicare Advantage plan (Part C) that includes drug coverage has its own unique formulary. This list is carefully curated by the insurance company in collaboration with a team of pharmacists and doctors.

The primary purpose of a formulary is to help manage healthcare costs while ensuring members have access to a wide range of effective medications. By including certain drugs and excluding others, plans can negotiate better prices with pharmaceutical manufacturers. Formularies typically include at least two drugs in the most common categories and classes, ensuring you have therapeutic alternatives for most conditions. It's crucial to understand that just because a drug is FDA-approved doesn't automatically mean it will be on your plan's formulary.

Step-by-Step: How to Check Your Plan's Formulary

Confirming whether your specific medications are covered is a vital step, both when you first enroll in a plan and each year during Open Enrollment. An unexpected coverage gap can lead to significant out-of-pocket expenses. Fortunately, there are several straightforward ways to check.

Step 1: Gather Your Information

Before you begin your search, it’s helpful to have a few key pieces of information ready. This will make the process much smoother and ensure you get accurate results. Prepare the following:

• Your complete list of prescriptions: Write down the exact name of each medication, the dosage (e.g., 20mg), and the frequency (e.g., once daily). Spelling is important, as many drug names sound similar.
• Your Medicare card: This has your Medicare number, which you may need if logging into a secure portal.
• Your plan information: Know the exact name of your Medicare Part D or Medicare Advantage plan and the company that provides it (e.g., Humana, Aetna, UnitedHealthcare).

Step 2: Use the Official Medicare Plan Finder Tool

The most reliable and comprehensive method is to use the official tool on the government's Medicare website. This tool allows you to compare different plans side-by-side based on the specific drugs you take.

To use it, visit Medicare.gov and navigate to the "Find health & drug plans" section. You'll be prompted to enter your ZIP code. You can then create a personalized list of your prescriptions. The tool will show you which plans in your area cover your medications and provide an estimated annual cost for each plan, including premiums, deductibles, and copayments for your specific drugs. This is the best way to get a complete picture of your potential costs.

Step 3: Check Your Plan's Website Directly

Every insurance company that offers a Medicare plan is required to make its formulary documents easily accessible to members and potential enrollees. Simply go to your insurance provider's website and look for a section related to "Pharmacy," "Prescription Drugs," or "Medicare Plan Documents."

Often, you will find a searchable online database where you can type in the name of your medication. Alternatively, they will provide a downloadable PDF document of the complete formulary. While convenient, remember to ensure you are looking at the document for the correct plan year, as these lists change annually.

Step 4: Call Your Plan Provider

If you're not comfortable using online tools or prefer to speak with a person, you can always call your plan's member services department. The phone number is printed on your insurance card. A customer service representative can look up your specific medications while you are on the phone and confirm their coverage status, what tier they fall into, and if any special rules apply.

Understanding Formulary Tiers

Once you find your medication on the formulary, you'll notice it's assigned to a "tier." This tier system is how plans categorize drugs to determine your out-of-pocket cost. While the exact structure can vary slightly between plans, most follow a similar five-tier model.

• Tier 1: Preferred Generic. These are the most common, low-cost generic drugs. They will have the lowest copayment or coinsurance.
• Tier 2: Generic. This tier includes other generic drugs that may be slightly more expensive than Tier 1 medications. Your copay will be higher than Tier 1 but still relatively low.
• Tier 3: Preferred Brand. This tier is for brand-name drugs that the plan has negotiated a better price for. They are more affordable than non-preferred brands but more expensive than generics.
• Tier 4: Non-Preferred Brand. These are brand-name drugs that have a generic alternative or are not part of a pricing agreement with your plan. Your cost-sharing for these drugs will be significantly higher.
• Tier 5: Specialty Tier. This tier is for very high-cost drugs used to treat complex or chronic conditions like cancer, multiple sclerosis, or rheumatoid arthritis. These drugs have the highest level of cost-sharing, which is often a percentage of the drug's cost (coinsurance) rather than a flat copay.

Understanding which tier your medication falls into is just as important as knowing if it's covered. A drug in Tier 4 or 5 can still result in substantial costs, even with insurance coverage.