Both Part D plans and Medicare Advantage Prescription drug plans have a formulary list that usually includes a tier pricing. In this post, we’ll explain what the Part D tiers mean and how they work. 

Formularies

The drug formulary includes both brand name medications and generic prescription drugs. The drugs contained in the formulary are chosen by a committee of healthcare professionals. The committee includes a team of doctors, nurses, pharmacists, and clinicians that work separately from the insurance provider. 

Throughout the year, the committee meets frequently to review the medications, the updated information from the Food and Drug Administration, clinical drug trials, and the safety of the prescription drugs. The prescription drugs that are contained in the formulary list are then placed in tiers. The lowest tiers have the cheapest prices while the costs increase along with the tiers. A lot of Medicare Part D plans use the four tier system, though some private insurers have up to five and six-tier systems. 

What the Tiers May Look Like

Keep in mind that each tier may be different, but an example of a Medicare Part D plan’s tier could look like this:

• Tier 1 – Usually consists of the lowest copayment with the most generic prescriptions.
• Tier 2 – Medium copayment with preferred, brand-name prescriptions.
• Tier 3 – Higher copayment with non-preferred, brand name prescriptions.
• Specialty Tier – Typically has the highest copayment, with high-costing prescriptions.

Larger Part D plan tier’s can look like this:

• Tier 1 – Usually consists of the lowest copayment with the most generic prescriptions.
• Tier 2 – Medium copayment with preferred, brand-name prescriptions.
• Tier 3 – Higher copayment with preferred, brand name prescriptions.
• Tier 4 – More costly than Tier 3, with non-preferred brand name prescriptions.
• Tier 5 (Specialty Tier) – Costs more than Tier 4.
• Tier 6 – Select care prescriptions.

How to Know What Tier Your Prescription Is In

To get the specific details about pricing and what tier your prescription may fall in, you will need to check your plan’s formulary and information. You should also be aware of your Part D rights. For example, suppose you have a prescription that is in a higher tier, and your doctor thinks you need this particular prescription rather than a similar one from a lower tier. In that case, you or your provider can ask your Part D plan for an exception to get a lower copayment, even though the prescription is in a higher tier. 

For more information about Medicare Part D, contact Game Changing Benefits today. We take the time to explain all of your options and guide you through the enrollment process.