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FAQs on Understanding Your Formulary



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Category: Understanding Your Formulary


Most Viewed FAQs in Category
Do any Medicare Part D plans ever cover extended or bonus drugs beyond the normal Medicare Part D 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, . . .

Is Ambien covered by any Medicare Part D carrier?
Although Ambien, in prior years, was covered by many Medicare Part D carriers, it is currently covered by a only few Medicare Advantage plans (MAPD) and one prescription drug plan (PDP).  Med . . .

What is Step Therapy in Medicare Part D?
Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a prescription medication.  Step Therapy requires that you try a less-expensive me . . .

What is a Prior Authorization in Medicare Part D?
Some medications are carefully monitored by Medicare Part D plans to ensure your safety and require that you receive prior approval from your plan before the prescription cost will be covered by t . . .

How are Drug Tiers defined on a Medicare Part D plan's formulary?
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 . . .

What are drug utilization management restrictions?
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 . . .

What if I have a prescription for a drug that isn't on my plan's list of covered drugs (formulary)?
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 . . .

Where can I find the size of the Medicare Part D prescription drug plan formularies?
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). . . .

What do I do if the medication I use requires "prior authorization?"
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 . . .

Where do I get a list of the number of pills I can get at one time?
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 . . .

Newest FAQs in Category
What is indication-based utilization management and how will it affect Medicare Part D plan members?
Indication-based utilization management (or indication limitations) is a newly introduced type of utilization management that a Medicare Part D prescription drug plan can implement along with the plan . . .

Do you have an online Formulary Browser that I can use to see the prescriptions covered by my Medicare Part D plan?
Yes.  We have our Formulary Browser online that includes every Medicare Part D and Medicare Advantage plan formulary or drug list and all formularies are formatted for alphabetical browsing.  . . .

What is a multi-source drug?
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 . . .

What are drug utilization management restrictions?
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 . . .

Do I get a Donut Hole discount on my non-formulary drug purchases and will these costs count toward getting out of the Donut Hole?
No.  Only Medicare Part D prescription drugs found on your formulary receive the brand-name or generic Donut Hole discount. Non-formulary medications, over-the-counter (OTC) drugs, and medicati . . .

I stayed with the same Medicare Part D plan as last year and now see that some of my medications are subject to Quantity Limits, Prior Authorization, and Step Therapy. What does this mean?
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 . . .

Where can I find the size of the Medicare Part D prescription drug plan formularies?
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). . . .

How do I find out whether my Medicare drug plan has a low-costing Tier One or Two medication that would substitute for my Tier Three prescription?
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 . . .

Is Ambien covered by any Medicare Part D carrier?
Although Ambien, in prior years, was covered by many Medicare Part D carriers, it is currently covered by a only few Medicare Advantage plans (MAPD) and one prescription drug plan (PDP).  Med . . .

Why am I being charged list price for my generics?
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 . . .






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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.