Are My Medications Covered? A Closer Look at A Formulary

When Medicare part D beneficiaries look at their plan information, they normally find an abridged formulary in the many things they are sent. There are some people that foolishly overlook the formulary and others that think the medications in the abridged form are all that is covered. When it comes to a Medicare part D plan, the formulary is very important and should be investigated through the year as well as when it's time to sign up for a new part D prescription drug plan.

What is a formulary?

A formulary is a list of medications, brand name and generic, that an insurance provider will help pay the cost for. When Medicare part D beneficiaries receive this information, it is telling them the medications their Medicare part D plan will help them pay for. This is something that is very important for anyone that takes medication, doesn't take medication or lives on a budget.

When a medication is listed on an insurance provider's formulary, these medications have a negotiated price and copay. If these medications are not listed on the formulary, the beneficiary will have to pay retail prices for those medications. The difference between the negotiated prices and retail prices of medications are staggering in some cases.

What medications are listed on a formulary?

Medications that are approved by a series of boards are listed on a company's formulary. These medications must be FDA approved and it must also have a medical benefit. If there is no proven, consistent medical benefit to the medication, it will not be placed on these lists of approved medications.

There are millions of medications available for people to take. Most of the medications that are listed on a Medicare part D prescription drug plan formulary are medications to help treat different illnesses. There are medications that have to be taken daily to help people maintain a person's health as well as medications that can be taken to get over an acute illness like the flu or a virus.

When a person is looking through their prescription drug plan's formulary, they should have a list of their medications with them. Their list should include how often the name of their medications, how often it's taken and the dosage amount. This is important because as they look through the formulary, they will see the quantity that is allowed on the formulary as well as the dosage allowed. If the medication isn't listed on the formulary, it is best that a call be placed to the insurance provider for confirmation it's a covered medication.

What medications aren't listed on a formulary?

Not all medications are covered by a Medicare part D prescription drug plan. These medications aren't always approved for various reasons. Many of the medications that aren't listed as approved medications fall into one of the following classifications:

  • medications for anorexia, weight loss or weight gain
  • fertility
  • cosmetic purposes
  • prescription vitamins or minerals(with the exception of prenatal vitamins and fluoride treatments)
  • barbiturates
  • benzodiazepines
  • medications for sexual or erectile dysfunction
  • medications paid by Medicare part A or part B

Many of the medications that aren't listed as approved often fall under different categories. Many people that run into this problem think that just because one insurance provider won't cover it, they can find these medications approved under another company. This isn't true; these lists are created by a higher authority than just the insurance provider.

Who makes up these lists?

There are a lot of people that want to know who makes the decisions as to what is placed on a Medicare part D prescription drug plan's formulary. This decision is something that isn't made without a lot of thought, consideration and research. Formularies are first discussed by the Centers for Medicare and Medicaid Services.

CMS has to think about the many different medications that are available for consumers to take and what medical purposes those medications serve. They have a board established that reviews the many different medications available and determines what medications can be placed on an insurance provider's insurance list.

Just because CMS says that a medication can be covered by their prescription drug plan doesn't mean that it will be covered. Each insurance provider has a separate board that reviews the CMS approved medications to determine what they will carry. Many times, they think about the most popular medications and what is economically feasible for that insurance provider to carry. Although the insurance provider has the final say to what they will provide coverage for, there are some guidelines they have to follow.

Every insurance provider that offers a part D Medicare prescription drug plan has to offer medications in the following categories:

·         antidepressants

·         antipsychotics

·         anticonvulsants

·         antiretrovirals

·         immunosuppressants

·         anticancers

The insurance providers have to offer medications in all therapeutic categories of prescription medications.

With the millions of medications that are offered for use, not every Medicare part D prescription drug plan provider will cover all of them. There will be some medications an insurance provider just won't carry for many different reasons. This is why it's important for Medicare beneficiaries to choose a prescription drug plan that works well with their prescription needs.

When a medication isn't on the drug plan formulary, there are many different ways to challenge that decision. When there is a medication that isn't on the formulary, members should speak with their insurance providers to get a better understanding of why not as well as their options. In some cases, these excluded medications will be allowed onto the formulary for that person.

A formulary isn't something that is made to hurt people. They are made to help cover the cost of the most commonly prescribed medications as well as the most effective medications. As people think of their medications, they should find an insurance provider that covers their medications. The difference between a limited formulary and an expansive formulary may be thousands of dollars for some people.

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