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If you have a chronic illness, taking regular prescription drugs may be an important part of maintaining your health. Since Original Medicare (Part A and Part B) doesn’t cover most prescription drugs you take at home, many Medicare beneficiaries look to Medicare Part D administered through private insurance companies.
Medicare Part D is prescription drug coverage for Medicare beneficiaries. You can get Medicare Part D coverage through either a stand-alone Part D plan to go alongside Original Medicare (Part A and Part B) or through a Medicare Advantage plan with prescription drug coverage.
Both Medicare Advantage plans and stand-alone Medicare Part D Prescription Drug Plans have formularies. A Medicare Part D formulary is simply a list of covered prescription drugs and vaccines. The formulary may change at any time, but your plan will notify you when necessary. Formularies can differ form plan to plan, but Medicare dictates some medications that all Medicare Part D formularies must cover.
Part D plans must also cover all or substantially all:
According to the Centers for Disease Control and Prevention (CMS) these drugs must be covered to “mitigate the risks and complications associated with an interruption of therapy for these vulnerable populations.”
Medicare Part D Formularies also generally cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness and not already covered by Medicare Part B. This includes the shingles vaccine, for example.
A non-exhausting list of prescription drugs excluded from Medicare Part D formularies include:
Medicare Part D formularies also generally don’t cover over the counter (OTC) medications such as Tylenol and Advil.
If your prescription drug is not on your Medicare Part D formulary, you may have to pay for that prescription drug out of pocket. Your other options are to:
What are the Medicare Part D formulary tiers?
Medicare Part D formulary tiers are ways to organize medications by price. The amount you pay for a prescription drug may depend on which tier your drug is on. A Medicare Part D formulary may categorize prescription drugs into five tiers:
Your plan might let you know when your prescription drug is moved to a higher cost-sharing tier.
Do you have any questions about your Medicare Part D formulary tiers? Feel free to enter your zip code on this page to browse Medicare plan options in your area .
eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies.