Medicare Part D Drugs and Formulary

How Medicare Covers Medicare Part D Drugs

Medicare Part D plans provide coverage for prescription drugs. Part D plans are offered by private insurers whose rates and coverage of different drugs can vary.

Part D Formulary List of Drugs

All Medicare Part D plans have a formulary. This is a list of drugs that the Part D insurer has put together to show you which drugs the Part D plan covers, and at what levels.

For example, one Part D plan might cover generic drugs with a $10 copay, certain brand-name drugs with a $25 copay, and still other brand-name drugs with a $35 copay. Any drugs that are not represented on the Part D list are considered "nonformulary." These drugs are either not covered at all by that Part D plan, or they might be covered at yet another benefits level, depending on the Part D plan.

Part D Changes to the Formulary List of Drugs

Medicare Part D insurers can make changes to its formulary list of drugs. However, it cannot remove drugs without telling you about it. And Part D plans cannot make changes to the listed drugs during certain times of the year.

Part D plans may not change the tier or how much you pay for covered drugs from the beginning of the Medicare Annual Enrollment Period (AEP) until 60 days after the start of the Part D coverage year. An exception to this rule is when the FDA determines that any Part D drugs are unsafe or a manufacturer removes Part D drugs from the market.

Midyear changes to the Part D formulary list of drugs require the Part D sponsors to notify enrollees of changes. The notification must include:

• The name of affected drugs
• Type of change
• Reason for change to the drugs listed
• Alternative drugs
• New cost sharing for impacted drugs
• Exceptions, if any, for those drugs

Find Out How Your Part D Plan Covers Different Drugs

Your Part D plan documents will specify how much you pay for drugs at different levels of your Part D plan's formulary list of drugs.

All Part D plans must make its formulary list of drugs available to the public. You can contact your Part D plan administrator or visit your Part D plan's website to get a copy of its current formulary list of drugs.

Part D Plan Enrollee Rights

Part D enrollees have the right to ask for the following about their plan for prescription drugs:

• "Coverage Determination" - This is a written explanation from your Part D plan about how drugs are covered, your costs for the drugs, any rules and requirements (such as prior authorization) for getting coverage to certain drugs, plus any exceptions to those Part D rules.
• Exceptions from your Part D plan administrator for drugs that are not on the formulary list of drugs.
• Exceptions to waive coverage rules.
• Exceptions for a lower copayment for drugs on a more costly tier. You may want to request this if you or your drug prescriber think you cannot take any of the less expensive drugs for the same condition.

Part D Rules for Certain Drugs

Although Part D plans may cover different prescription drugs, all Part D plans must cover all commercially available vaccines when medically necessary to prevent illness. The only exception to this is vaccines covered by Part B plans. Any drugs covered by Medicare Part A and Medicare Part B plans are not included in Part D formularies.

Drugs that are restricted by Medicaid are also excluded from Part D formularies with the exception of smoking cessation drugs. Those drugs excluded from Part D plans include: weight loss or weight gain drugs, fertility drugs, cosmetic or hair growth drugs, non-prescription drugs, barbiturates, and sexual or erectile dysfunction drugs.

Medicare has neither reviewed nor endorsed this information.