Medicare Part D Prescription Drug Plan

• Medicare Part D plans covers a wide range of prescription drugs.
• Medicare Part D plans including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDs.
• Medicare Part D plans come with a list of covered drugs (formulary) specific to the plan.
• Medicare Advantage and Medicare Part D plans place drugs into different levels called “tiers” on their formulary. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.

• Tier 1—lowest copayment: most generic prescription drugs
• Tier 2—medium copayment: preferred, brand-name prescription drugs
• Tier 3—high copayment: brand-name prescription drugs
• Tier 4—higher copayment: non-preferred, brand-name prescription drugs
• Tier 5—highest copayment: Specialty tier highest cost prescription drugs

Medicare Part D Formulary Exception

• Medicare drug plans may have these coverage rules:
  • Opioid pain medication safety checks
  • Prior Authorization
  • Quantity limits
  • Step therapy
  • Part D vaccine coverage
  • Drugs you get in hospital outpatient settings

• If you or your prescriber believe that one of these coverage rules should be waived, you can ask your plan for an Exception.
• Your prescriber (doctor) feels you need a higher Tier drug instead of a similar lower Tier drug, your prescriber may ask your plan for a Formulary Exception. Tier reduction to lower your co-pay may also come into play.