Medicare Part D Health Article

Medicare Part D: What is a Formulary?

A formulary is a list of medications that a health plan or Medicare Part D plan covers. Each Medicare Part D formulary must be approved by the Center for Medicaid and Medicare Services (CMS). Regulations specify that formularies must include at least two drugs in each therapeutic category and pharmacologic class  of products covered by Part D. Each plan can choose which medications they will cover within these categories and classes, and they aren't required to cover all FDA approved prescription medications, with a few exceptions:

            All of the medications in the following categories must be covered:

• Antidepressants
• Antipsychotics
• Anti-seizure agents
• Immunosuppresants
• Retrovirals for HIV/AIDS
• Antineoplastics
• Insulin and supplies
• Vaccines
• Smoking-cessation products
• Self-administered injectable and infused medications

The following medications are not covered by Medicare Part D plans:

• Over-the-counter drugs
• Drugs for weight control (including anorexia)
• Medications for fertility
• Cosmetic medications
• Barbiturates
• Benzodiazepines
• Vitamins  (except prenatal vitamins and fluoride preparations)

Medicare Part D plans have tiered formularies where some medications the plan has designated as "preferred drugs" have a lower level of cost-sharing while drugs the plan considers "non-preferred" can have a higher level.

Insurance companies that provide Medicare Part D plans are being scrutinized for changing formularies and raising prices once seniors are enrolled.  Plans are not permitted to make formulary changes between the beginning of initial enrollment and the first 60 days of the contract year. Additionally, companies must notify CMS monthly of any proposed changes to the formulary and other cost-containment strategies so that the agency can verify that the plan meets Medicare standards.

Some Medicare Part D plans have a fail-first policy or step therapy. This means the plan will only dispense a drug if a person has tried a lower-tiered, less expensive medication that has not worked for them or if they are unable to tolerate side effects.

A new feature of the Medicare Part D program is the exceptions process, which allows members of a plan to appeal for coverage of a non-covered medication. Request your physician's help in requesting that your plan grant an exception if your plan has denied coverage of a medication that you need. Describe the problem you are having, and how the plan's actions will be harmful to you. Clearly state what steps you would like the plan to take to remedy the situation. Plans must make coverage determinations within 72 hours, unless there is an emergency or a delay that could result in harm to the patient. If there is an emergency, the plan must reply within 24 hours.

It's important to understand your plan's formulary. Know what medications are prescribed for you and make sure they are covered by the plan of your choice.

Lipowski, Earlene Ph.D. Drug Topics Unraveling Medicare Nov 7, 2005.

You can use Healthline's Part D Plan Selector to find which plan might be right for you. Click here to learn more.