What are drug tiers?
Many prescription drug policies in Part D classify prescription drugs at different levels of cost sharing or tiers. A drug in a lower level costs less than a drug in a higher level. If your doctor prescribes a drug at a higher level than a similar drug at a lower level, you may be able to make an exception and receive a lower copayment. You can also ask your prescriber or your doctor if there is a generic or cheaper drug that can be effective to treat your condition.
This is an example of how a policy can divide your drug levels/tiers:
Level 1 – Most generics. Tier 1 drugs cost less.
Level 2 – Preferred brand names. Tier 2 drugs may cost more than Tier 1 drugs.
Level 3: Non-preferred brand drugs. Tier 3 drugs may cost more than Tier 1 and Tier 2 drugs.
Level 4 – Special medications. Tier 4 drugs are generally unique and very expensive drugs and are likely to have the highest co payment or co insurance.
What rules apply to prescription drug coverage?
Many Medicare prescription drug policies use rules or restrictions on insurance for certain prescription medication. Coverage rules promote the proper use of medications when they are medically necessary, and these rules also help control the cost of the solution policy. Some types of specific rules include:
Pre-approval: If your policy requires prior approval for a drug you are taking, you or your doctor must contact the policy before you can complete your prescription. Your doctor must prove that there is in fact a reason medically necessary why you need to use this specific medicine to be insured by your policy.
Step Therapy: This is a policy that requires you to first try a similar low-cost drug that has been shown to be effective on most people with your condition before you can switch to a more expensive drug. If you have already tried a cheaper drug and it has not worked or if your doctor thinks that your condition requires you to take more expensive drugs from a medical point of view, you can use your policy to get an exception.
Quantity limit: For reasons of safety and cost, policies may limit the amount of drugs they cover over a period of time. For example, a policy can only include a 30-day supply of medication for heartburn. If you need more, your doctor may need to include more information about your condition in the policy.
What happens if my Part D policy does not insure my prescription drugs?
If you are a member of an independent prescription drug policy or a Medicare Advantage policy with prescription drug coverage, you have options and rights if your drug is not listed in formulary of your plan:
You can ask your doctor if you can change to another drug that is in the formula. If you have paid for an out-of-pocket drug that you think should have been your policy, you can request reimbursement from the policy by requesting coverage.