How to Read a Medicare Part D Formulary

PDP Formulary

While intimidating, you can learn how to read a Medicare Prescription Drug Formulary

If you are covered by a Medicare Part D prescription drug plan – or you are considering the purchase of such a plan – it is important to have a good understanding of what exactly is and is not covered.  You can find what’s covered within your Drug Formulary.

Unlike Medicare Part A and Part B (also known as Original Medicare), the many Medicare Part D drug plans that are available in the market today are not offered directly by Medicare itself, but rather through private insurance carriers.

Because of that, Medicare Part D plans can vary – sometimes significantly – from one to another with regard to the premium that is charged, as well as regarding the medications that may be covered (and in turn, the extent of that coverage).

What is a Drug Plan Formulary?

A Medicare Part D formulary is a list of prescription medications that is used by practitioners in identifying drugs that may offer the greatest overall value. These medications can include both brand name and generic options.
Formularies are required to include a wide range of different medications in the most commonly prescribed classes and categories. This can help to better ensure that enrollees who have different medical needs can obtain the medication that they require.

Understanding the Medicare Part D Formulary Information

Medicare Part D drug formularies are organized according to the following categories:

  • What is covered
  • How a medication is covered
  • Restrictions

In the section on what is covered, the name of the medications will be listed on the left hand side, and they are grouped alphabetically by their therapeutic category. To the right of the What is Covered section is the category of How It Is Covered. Here you will find the tier number that is assigned to each of the medications. To the right of that, you will find details on any restrictions that may apply to each particular drug.

In the Restrictions area, there are a number of different abbreviations that you may find. These can include the following:

  • PA – PA stands for Prior Authorization. In this case, before the Medicare Part D plan will cover a certain drug, it will be required that either your doctor or other prescriber first show that the medication is medically necessary.
  • QL – QL refers to Quantity Limits. If this abbreviation is shown, it means that the plan may be limited in the amount of medications it covers during a particular period of time. This could be for cost and / or safety reasons.
  • ST – The abbreviation ST means Step Therapy. Here, it may be required that the plan enrollee try using an alternate medication – which are oftentimes less costly – before they are allowed to “step up” to a more expensive medicine.

Related Post: “How to Choose the Right PDP Plan?”

The Takeaway:

While the Medicare Part D formulary may at first seem to be somewhat intimidating, knowing what to look for can be extremely helpful in pointing you in the right direction with regard to which drug plan may be best for you and your specific needs.

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Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.