Network Pharmacies

Medicare drug plans have contracts with a number of pharmacies that are part of the plan’s “network.” Your plan may not cover your prescription if you don’t go to a network pharmacy. Along with retail pharmacies, your plan’s network may include preferred pharmacies, a mail-order program, and a 60 or 90-day retail pharmacy program…read full article 

List of covered prescription drugs (Formulary)

Each Medicare drug plan will have a list of prescription drugs that it covers. Plans cover both generic and brand-name prescription drugs. The drug lists must include a range of drugs in the most commonly prescribed categories and classes…read full article 

Generic Drugs

According to the Food and Drug Administration (FDA), a generic prescription drug is the same as a brand-name prescription drug in safety, strength, quality, the way it works, how it’s taken, how much should be taken, and the way it should be used…read full article 

Tiers

Many Medicare drug plans place drugs into different “tiers.” Drugs in each tier have a different cost. Some plans may have more tiers and some may have less…read full article 

Coverage Rules

Plans may have coverage rules to make sure that certain drugs are used correctly and only when necessary. These rules may include prior authorization, step therapy, and quantity limits as in other articles in this section. 

Prior Authorization

Some prescription drugs are more expensive than others even though some less expensive prescription drugs work just as well. Other prescription drugs may have more side effects, or have restrictions on how long they can be taken…read full article 

Step Therapy

Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition…read full article  

Example of Step Therapy

Step 1—Dr. Smith wants to prescribe a new sleeping pill to treat Mr. Mason’s occasional insomnia. There is more than one type of sleeping pill available. Some of the drugs Dr. Smith considers prescribing are brand-name only prescription drugs covered by Mr. Mason’s Medicare drug plan…read full article 

Quantity Limits 

For safety and cost reasons, plans may limit the quantity of prescription drugs that they cover over a certain period of time…read full article 

What do I do if my plan won’t cover a prescription drug I need?

If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you are required to pay, you have the right to the following…read full article