What is a Prescription Drug Plan Formula?

What is a Prescription Drug Plan Formula?

If you have a Part D prescription drug plan or a Medicare Advantage Prescription Drug Plan from a private insurance company, you can assume that all your prescription drugs are insured. One way to know in detail what controlled medications are included in your plan is to review the plan formula. A formula is simply a list of prescription medications insured. If your prescription is not in the plan, you may have to pay 100% out of pocket. In general, you will receive a copy of the form by calling your plan or visiting the site of your plan. When conducting an online survey, you should be aware that a form can also be called a “prescription drug guide” or “medication list.”

Levels of Medicare formulation

The cost of your prescription medication may depend on the level of your medication and also if you are meeting your prescription plan at a network pharmacy. A form of Medicare can classify prescribed medications in five stages:

Level 1: Preferred Generics: These are the prescribed medications that usually have the lowest cost to you.

Tier 2 – generics: these medications generally have a greater cost sharing than Tier 1 drugs.

Level 3 – The preferred brand: controlled medications cost less than level 4.

Level 4: Non-preferred medications: prescribed medications cost less than level 5

Level 5: these are the most expensive medications, including some injectable medications

Your plan can indicate if your prescription drug moves to a higher cost-sharing level.

Medicare formulation requirements

Although the form of Medicare Part D is different, they must guarantee all specific categories and be added to Medicare Supplement Plans 2019 or a penalty is given. One category is:

All vaccines available in the market are medically necessary for the prevention of diseases (in addition to those insured by Medicare Part B). These include the herpes zoster vaccine, the tetanus vaccine, the pneumonia vaccine and much more. This means that if your doctor recommends a vaccination, this is usually ensured by your Part D plan.

Part D plans must also include all or substantially all:

  • Immuno-suppressors (to avoid rejection of organ transplants)
  • Antidepressants (for the treatment of depression).
  • Antipsychotics (for the treatment of mental disorders)
  • Anticonvulsants (for the treatment of seizures).
  • Antiretroviral agents (for the treatment of HIV / AIDS)
  • Antineoplastic agents (to prevent the growth and spread of precancerous cells, tumors or cancer cells)

This means that if you have an organ transplant, have depression or another mental illness, have seizures or HIV infection or need some type of treatment for a pre-cancer condition, your Part D plan generally guarantees some of these medications.

Changes in the form of Medicare: A form may change from time to time, but the board must notify you if the change affects it. Normally, the plan informs in advance about the change, so that you do not run out of medication. A form may change when a new, cheaper prescription drug is published or when new safety information about a prescribed drug is published.