Frequently Asked Questions about Understanding Your Formulary

Yes.  Some Medicare Part D prescription drug plans cover, not only brand-name and generic prescription drugs, but also so-called "Bonus Drugs" not usually covered by the Medicare Part D program, . . .

Utilization management restrictions (or "usage management" or "drug restrictions") are controls that your Medicare Part D (PDP) or Medicare Advantage plan (MAPD) can place on your prescription drugs a . . .

Although Ambien, was covered by many Medicare Part D carriers in prior years, it is currently covered by only a few Medicare Advantage plans (MAPD) and no prescription drug plans (PDP). Instead . . .

Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a formulary medication. If you have a formulary drug subject to Step Therapy, you ar . . .

Some medications are carefully monitored by Medicare Part D plans to ensure your safety and your plan may require that you receive prior approval or "prior authorization" before your prescription will . . .

Drug Tiers are an attempt to "logically" group drugs (such as generics, preferred-generics, brand drugs, and specialty drugs) within a list (drug formulary). All of your Medicare Part D prescriptio . . .

Some abbreviations on your Medicare Part D plan's formulary are for Usage Management Restrictions or to further clarify the coverage details under your particular Medicare Part D prescription drug pla . . .

A National Drug Code (NDC) is a number that uniquely identifies your prescription medication, the drug manufacturer, the medication strength, and the packaging of your medication. An NDC can be up . . .

Quantity Limits (QL) are a Medicare Part D plan drug utilization management tool limiting the amount of a particular drug that the Medicare Part D plan will cover during a specified time period, such . . .

We include the size of all Medicare Part D prescription drug plan formularies in our stand-alone Medicare Part D Plan Finder (PDP-Finder.com) and our Medicare Advantage Plan Finder (MA-Finder.com). . . .

If your pharmacist tells you that one of your Medicare Part D prescription drugs requires prior authorization (PA), you should contact your Medicare Part D plan to find out about the PA requirement an . . .

Medicare Part D prescription drug plans can change their plan formulary or drug list throughout the plan year - and you may find that new Part D drugs are added - or dropped - or formulary drugs may h . . .

If you have a prescription for a drug that isn't on your plan's formulary, you should ask your doctor if there is another drug you can take that is on your plan's formulary.  If your doctor can't . . .

This is known as a quantity limit restriction (such as 30 / 30 days or 30 pills for 30 days).  You can review your Medicare Part D plan's formulary for any Usage Management Restrictions or to f . . .

A Coverage Determination is any decision made by a Medicare Part D plan regarding payment or coverage benefits to which a Medicare plan enrollee believes he or she is entitled. More specifically, . . .

Yes.  We have our Formulary Browser online that includes every Medicare Part D prescription drug plan (PDP) and Medicare Advantage plan (MAPD) formulary or drug list - and all plan formularies ar . . .

To learn more about low-cost insulin coverage, you can:Contact the Medicare drug plan's Member Services Department,Review the drug plan's Evidence of Coverage document,Speak with a Medicare representa . . .

It depends on the type of formulary change.(1) No notice of a formulary change when replacing a brand-name drug with a new generic.Your Medicare drug plan (stand-alone Medicare Part D plan or Medicare . . .

You and/or your prescriber can use our online Formulary Browser (https://FormularyBrowser.com) to check your Medicare Part D (PDP) or Medicare Advantage (MAPD) plan's drug list (formulary) for lower-c . . .

No. The 75% Donut Hole discount, does not apply to Medicare Part D excluded drugs even if they are covered by the Medicare Part D prescription drug plan as a “Bonus Drug” (also known as &# . . .

Utilization management restrictions (or "usage management" or "drug restrictions") are controls that your Medicare Part D (PDP) or Medicare Advantage plan (MAPD) can place on your prescription drugs a . . .

Some Medicare drug plans will mail printed abridged or shortened versions of the plan's complete drug list showing only a portion of the plan's covered prescriptions. Our Q1Medicare Formulary Browser will show all drugs covered by the plan along with additional coverage info.

Yes.  We have our Formulary Browser online that includes every Medicare Part D prescription drug plan (PDP) and Medicare Advantage plan (MAPD) formulary or drug list - and all plan formularies ar . . .

To learn more about low-cost insulin coverage, you can:Contact the Medicare drug plan's Member Services Department,Review the drug plan's Evidence of Coverage document,Speak with a Medicare representa . . .

Indication-based utilization management (or indication limitations) is a type of utilization management that a Medicare Part D prescription drug plan can implement along with the plan's prior authoriz . . .

Multi-source drug is a term used by the Centers for Medicare and Medicaid Services (CMS or Medicare) distinguish between: Generic / Preferred Multi-Source Drug and Other Drugs . . .

You and/or your prescriber can use our online Formulary Browser (https://FormularyBrowser.com) to check your Medicare Part D (PDP) or Medicare Advantage (MAPD) plan's drug list (formulary) for lower-c . . .

Quantity Limits (QL) are a Medicare Part D plan drug utilization management tool limiting the amount of a particular drug that the Medicare Part D plan will cover during a specified time period, such . . .

No.  Only Medicare Part D prescription drugs found on your formulary receive the brand-name or generic 75% Donut Hole discount. Non-formulary medications, over-the-counter (OTC) drugs, and med . . .

Medicare Part D plans can change formulary or drug list designs each year and with the new plan year, your Medicare prescription drug plan may have implemented utilization management (or drug usage ma . . .

We include the size of all Medicare Part D prescription drug plan formularies in our stand-alone Medicare Part D Plan Finder (PDP-Finder.com) and our Medicare Advantage Plan Finder (MA-Finder.com). . . .

Although Ambien, was covered by many Medicare Part D carriers in prior years, it is currently covered by only a few Medicare Advantage plans (MAPD) and no prescription drug plans (PDP). Instead . . .

You may be paying full retail cost for your generic medications for a few reasons: You could be in the deductible phase of your Medicare Part D coverage and you are responsible for 100% of you . . .

Medicare Part D prescription drug plans can change their plan formulary or drug list throughout the plan year - and you may find that new Part D drugs are added - or dropped - or formulary drugs may h . . .

This is known as a quantity limit restriction (such as 30 / 30 days or 30 pills for 30 days).  You can review your Medicare Part D plan's formulary for any Usage Management Restrictions or to f . . .

Co-Payment or Co-Pay is a type of cost-sharing that refers to a fixed dollar amount you pay for a medication assigned to a logical grouping or Tier of medications. Medicare Part D plans group the . . .

Co-Insurance is a type of cost-sharing that refers to the payment of a percentage of the medication's negotiated retail drug cost that you would pay for a medication assigned to a logical grouping or . . .

As noted by the United States Food and Drug Administration (FDA): "The term “authorized generic” drug is most commonly used to describe an approved, brand name drug that is marketed a . . .

Some abbreviations on your Medicare Part D plan's formulary are for Usage Management Restrictions or to further clarify the coverage details under your particular Medicare Part D prescription drug pla . . .

It depends on the type of formulary change.(1) No notice of a formulary change when replacing a brand-name drug with a new generic.Your Medicare drug plan (stand-alone Medicare Part D plan or Medicare . . .