Who Makes Medicare Formulary Decisions?

There are times that Medicare part D beneficiaries don’t understand why they can’t have certain medications filled under their Medicare prescription drug plan. There are some medications that are necessary in their eyes but they aren’t covered under certain formularies. When things aren’t covered, it can come as a nasty surprise to those that aren’t expecting that response when they go to the pharmacy to pick up their medications. When people are told they can’t have a certain medication, they often wonder who makes the decisions on what will be covered on these plans.

Decision Makers

A lot of Medicare beneficiaries mistakenly think that insurance providers decide what will be covered under their part D prescription drug plans. That is something that isn’t entirely true. There is a list and certain guides that have to be followed regarding what can and can’t be offered under a Medicare prescription drug plan. The insurance companies may choose from the lists of medications but they don’t make the list of medications. Those decisions are made by a different entity.

There is a huge committee of people professions that come together to make the decisions of what medications will be covered on these formularies. When new medications are released to be sold to the public, this committee has to come together to make a decision as to if they will allow the Medicare prescription drug plans will carry them. The committee is made up of people from:

·         Social Security Administration

·         Pharmacists

·         PBM (pharmacy benefit managers)

·         Centers for Medicare and Medicaid Services

The people that are on this committee have specific things they have to consider and regulations to work out. They are put on the same committee to discuss and make the best decisions for Medicare beneficiaries.

Social Security Administration

Many people don’t realize the power the Social Security Administration holds when it comes to Medicare. This is the entity that funds the program and will have to be involved in the decisions concerning Medicare. Because medications cost money, Social Security has to be involved to ensure they are able to offer medications that won’t bankrupt the program.


Medications are very complex things. There are some medications that are more harmful than good and some medications have been improved to work more efficiently than older medications. Rather than allow all medications be placed on the formularies, pharmacists are able to evaluate the medications that are most commonly prescribed and the ones that are most efficient. Pharmacists are able to help keep the best medications available to those that need it rather than allow people to take medications that aren’t efficient or in the best interests of their health.

PBM (Pharmacy Benefit Managers)

Pharmacy benefit managers are people that most Medicare beneficiaries haven’t heard of. The representatives of PBMs are those that have to help work out the processing of the medications. This is the group of individuals that is responsible for processing the claims for any medications and paying the pharmacies. When there is a new medication to be introduced to the Medicare system, the pharmacy benefit managers have to know how to process the medications as well as the pricing of the medications. Without these individuals, they can’t be processed through a Medicare prescription drug plan.

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services is who oversees the entire Medicare Part D program. This entity is the one that has to govern the program’s rules and regulations. They have to help the other committees to find the best way to regulate these medications. They have to make sure the medications aren’t a conflict with existing rules. CMS has to be a part of any major decisions that will change the offerings of a Medicare prescription drug plan.

There are many things that have to be taken into consideration when it comes to the medications that are offered on a Medicare part D prescription drug plan. Although many beneficiaries think it’s easy to put a medication on the formulary, it’s not. There are some medications designed to support a person’s lifestyle decisions and others are designed to support a person’s health and medical ailments. The only medications that are supported on a Medicare prescription drug plan are those that are for medical and health ailments.

This committee is one that takes the time to study a medication before allowing it to be put on a formulary. There are times that a medication can be used to help a serious ailment. In those instances, there may be something that can be done to allow that medication to be covered on the formulary. When the committee hears about these things, they take the time to put provisions into effect so no beneficiary has to suffer when they can prevent it.

The purpose of this committee isn’t to make life harder for the Medicare beneficiaries that depend on their part D prescription drug plan. They are brought together because of their expertise in their fields to give Medicare beneficiaries the best medications available. They want the medications to be affordable and freely available to those that need it. Medicare part D prescription drug plans have an expansive formulary that helps many maintain their health for years. 

Nov. 17 12'
smyli12October 15, 2011 i don't think you need medication for this at all. i think maybe you shulod make yourself get out into the world. of course this is hard but ask your family or friends for support. you could say i have social anxiety too, but i know i don't need medication.
Jul. 7 15'


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