A formulary is a list of each drug covered by a Medicare Prescription Drug Plan (Part D) and Medicare Advantage Plan (Part C).
Coverage for a specific drug may vary from plan to plan. Each Medicare plan has its own unique formulary, meaning that it has its own unique list of drugs the plan covers. Formularies include both brand-name and generic drugs, and they must include most types of drugs used by Medicare beneficiaries. You can typically find a plan’s formulary with the plan’s other documents and details.
Each Medicare drug plan must give at least a standard level of coverage set by Medicare. Plans can vary on pharmacies they use, prescription drugs they cover, and how much they charge. Plans design their prescription drug coverage using different methods.
Medicare plan formularies are typically created by a committee set up by the plan’s health insurance company. The formulary committee would likely include pharmacists and doctors from various medical areas. This committee would then choose which prescription drugs to include on the health plan formulary. A health plan may change its formulary drug list from time to time. That may be because new drugs become available, changes in treatment or based on new medical information.
Formularies vary. Every plan creates its own formulary structure, decides which drugs it will cover and determines which tier a drug is on. One plan may cover a drug that another doesn’t. The same drug may be on tier 2 in one plan’s formulary and on tier 3 in a different plan’s formulary.
Formularies change. A plan may add or remove a drug from its formulary or move a drug into a different tier. Usually, plans must inform members in advance if a drug is to be removed.
Formularies have different pricing. Plan members typically pay a copay or coinsurance each time they fill a prescription. How much you pay depends on the plan you have. Two plans may cover the same drug, but the cost may be different.
It’s important to research and compare plans to make sure your prescription drugs are covered at a price you are comfortable with.
A tiered formulary divides drugs into groups based mostly on cost. A plan’s formulary might have three, four or even five tiers.
Each plan decides which drugs on its formulary go into which tiers. In general, the lowest-tier drugs are the lowest cost. Plans negotiate pricing with drug companies. If a plan negotiates a lower price on a particular drug, then it can place it in a lower tier and pass the savings on to its members.
The table below is an example of a four-tier formulary structure.
Drug Tier | Type of Drugs Included | Your Cost |
|---|---|---|
Tier 1 | Most generic drugs | Lowest copay |
Tier 2 | Most common brand name drugs Preferred brand name drugs Some high cost generic drugs | Moderate copay |
Tier 3 | Non-preferred brand name drugs | Highest copay |
Tier 4 | Unique or very high cost drugs | Percentage of total drug cost, called coinsurance |
Medicare prescription drug plan formularies may change on a yearly basis.
It’s important to check your plan details every year to make sure the medications you need are still covered.
If you find that your plan no longer covers a medication you need, Lehigh Partners Senior Benefits can help you find a plan that provides the right coverage for your unique situation.
The Medicare Decision That Matters More Than You ThinkIf you’re turning 65 soon, I don’t need to tell you that your mailbox has probably turned into a war zone of Medicare ads. Shiny brochures. Friendly-looking seniors. Confusing charts. And somehow… nobody’s giving you a straight answer. Here’s what I’ve learned after helping people with Medicare for over
Read MoreWhen it comes to Medicare Supplement plans, it’s easy to feel overwhelmed by all the choices.If you’ve heard about Plan G but aren’t sure exactly what it covers – or whether it’s the right fit – you’re in the right place. Medicare Plan G is a popular Medicare Supplement plan in 2025 because it covers most
Read MoreTL;DR – Top Medicare Mistakes to Avoid When Turning 65 Choosing a plan based only on the premium: $0 Medicare Advantage plans often come with hidden costs. Missing the Medigap open enrollment window: After 6 months, you could be denied or charged more. Thinking COBRA protects you: It doesn’t delay your need to enroll in
Read More✅ TL;DR: Medigap Plan G offers the most comprehensive Medicare Supplement coverage available in 2025. It’s not the cheapest, but it helps you avoid surprise bills, see any doctor who accepts Medicare, and enjoy predictable healthcare costs. For many turning 65, it’s the safest long-term choice. Plan G costs how much?! Medicare decisions can feel
Read MoreThe $1,200 Wake-Up CallA few years back, I got a call from a woman named Janet who had just retired after 40 years in education. She was sharp, organized, and had always handled her benefits like a pro. But that call wasn’t a happy one.She was sitting at the pharmacy counter, trying to pick up
Read MoreIt Starts the Way It Always Does…You’re turning 65. The mailbox is overflowing. Your phone won’t stop ringing. You can’t even watch Judge Judy without hearing about free flex cards and $0 premiums. Suddenly, you’re the most popular person in the Medicare universe.It’s not just confusing — it’s exhausting. Every flyer screams urgency. Every call promises savings.
Read MoreCall us
Call Lehigh Partners at 1-833-265-9655
Licensed insurance agents are available to help you through enrollment and beyond.
Tags
As the population ages, there is an increasing need for specialized healthcare services catered towards seniors. Medicare, a federal health insurance program primarily designed for individuals aged 65 and above, plays a crucial role in providing affordable healthcare coverage. However, navigating through the complexities of Medicare can be overwhelming for seniors. This is where Senior
Read MoreAre you searching for the best Medicare insurance agency in Bethlehem? With a plethora of options available, it can be overwhelming to choose the right agency for your specific needs. In this comprehensive guide, we will walk you through the essential factors to consider and highlight some key characteristics of the finest Medicare insurance agencies
Read MoreTo switch your Medicare drug (Part D) plan, follow these steps:Joining a new plan: You can switch to a different Medicare drug plan by joining another drug plan during specific enrollment periods. These enrollment periods include the Annual Enrollment Period (October 15 – December 7), the Medicare Advantage Open Enrollment Period (January 1 – March
Read MoreThe Importance of a Free Medicare Part D EvaluationLehigh Partners’ convenient, free Medicare Part D evaluation can help eligible customers better understand their options in minutes. Medicare Part D is an essential program that provides prescription drug coverage to millions of Americans. As the cost of medications continues to rise, it is crucial for Medicare beneficiaries
Read MoreDiscover six important actions you can carry out during the Annual Election Period to enhance your Medicare coverage. The enrollment period, which takes place every year from the 15th of October to the 7th of December, gives you the flexibility to do 6 things.Discover the 6 actions you can take during the Medicare Annual Election
Read MoreThe Medicare Annual Enrollment Period takes place from October 15 to December 7 each year, allowing you to assess and modify your Medicare coverage based on your changing healthcare needs. To make the most of your Medicare coverage in 2024, here’s some information to help you prepare for the Medicare Annual Enrollment. Key pointsIf you’re
Read MoreProtect yourself and your loved ones this flu season — get your flu shot. For better protection against flu, the CDC recommends people 65 or older get one of the higher-dose flu vaccines, if available. Stay proactive in safeguarding yourself and your loved ones during flu season by getting the recommended flu shot, especially if
Read MoreMedicare, the federal health insurance program for people aged 65 and older (as well as certain individuals with disabilities), offers several coverage options to meet the diverse needs of beneficiaries. For Medicare-eligible individuals, understanding the different choices available can be overwhelming. In this article, we will explore the pros and cons of three primary coverage
Read More