Medicare Part D

MEDICARE PART D: PRESCRIPTION DRUG INSURANCE

Plan Restrictions

Formulary Status (cost generally rises as the tier number increases)
Tier 1 = generic brand
Tier 2 = most commonly purchased by consumers (generic or brand name)
Tier 3 = brand name
Prior Authorization
Yes = must check with the insurance company to be sure the drug is on their formulary
No = no permission is required from the insurance company before purchasing the drug
Step Therapy
Yes = there is a specified sequencing of drugs; the plan specifies where you have to start
No = there is no sequence of drugs or no limitations on starting at any step in sequence
Quantity Limits
Yes = you pay out-of-pocket for any amount over what the plan has specified will pay
No = the plan pays for whatever amount the doctor prescribes for you

Some plan formularies are more restrictive than others. Plan restrictions may enter into your decision to select a certain plan. The more “yes” responses for a plan, the more work for the consumer to contact plan representative, doctor, and/or pharmacist to be sure restricts are met.