Medicare Part D formulary

Each Medicare prescription drug plan has its own list of covered drugs, known as a formulary. Our pharmacists and doctors update the drug lists each year based on the latest medicine and treatment information, which helps us include the safest and most effective prescription drugs available.

As you look through a drug list, you may notice that your plan places drugs into different tiers.

Drugs in each tier have different costs. Knowing what tier your drug is in, together with looking at your plan’s benefits, can help you predict how much that drug will cost. Drugs in lower tiers generally cost less than drugs in higher tiers.

HealthPartners Medicare Advantage plans have five tiers:

• Tier 1: Preferred generic drugs – This is the lowest tier. Lower-cost, commonly used generic drugs are in this tier.
• Tier 2: Generic drugs – High-cost, commonly used generic drugs are in this tier.
• Tier 3: Preferred brand drugs – Brand-name drugs without a lower-cost generic therapeutic equivalent are in this tier.
• Tier 4: Non-preferred drugs – Higher-cost generic drugs and brand-name drugs with a lower-cost generic therapeutic equivalent are in this tier.
• Tier 5: Specialty drugs – This is the highest tier. Unique and/or very high-cost generic and brand-name drugs are in this tier.

Both prescription medicines and over-the-counter medicines can have brand-name and generic versions:

• Brand-name and generic drugs use the same active ingredients, and they have the same dosage, strength, instructions and use.
• The Food and Drug Administration (FDA) requires generic drugs to be as effective as brand-name drugs.
• The main differences between generic and brand-name drugs are their appearance and cost. Trademark laws require generic drugs to look different from brand-name versions. Generic drugs also usually cost less than the brand-name versions.

Brand-name drugs that are more complex than typical drugs are called biological products (or biologics). Some biologics have alternative options called biosimilars. Generally, biosimilars work just as well as their biologic counterpart. They usually cost less, too.

Specialty drugs are generally ordered through a specialty pharmacy. They tend to be high-cost drugs used to treat complex, chronic or rare conditions, like cancer, multiple sclerosis (MS) or rheumatoid arthritis (RA).

It depends. If your plan has a deductible, you’ll need to pay the full cost of each prescription that applies toward the deductible until the deductible is met. After that, HealthPartners will share the cost of your prescription drugs. The amount you’ll pay is determined by the tier your drug is in and your plan’s benefits. Keep in mind that not all tiers may apply toward the deductible. That means your HealthPartners plan may share the cost immediately for some prescriptions.

If you qualify, Medicare could pay up to 100% of your drug costs through the Medicare Extra Help program. This could include monthly prescription drug premiums, annual deductibles and coinsurance.

Finally, the amount you pay can depend on where you fill your prescriptions. The cost can be different at a network pharmacy, an out-of-network pharmacy or a mail order pharmacy.

Sometimes covered drugs have extra requirements or limits.

Certain drugs, even if they’re on the drug list, may require prior authorization. This means you’ll need to get approval from HealthPartners before you fill your prescription. Be sure to check before you fill a prescription for a drug you haven’t used before. If you don’t get prior approval, your drug may not be covered.

You can review our Medicare drug list prior authorization criteria (PDF) .

Some drugs have limits on the amount we’ll cover – for example, we may cover only a 30-day supply for refills. There may also be a limit on the quantity of a specific prescription that we’ll cover in one day.

In some situations, you may be required to try another drug before we cover the drug you’re requesting. For example, if Drug A and Drug B both treat your medical condition, HealthPartners may not cover Drug B until you try Drug A first. If Drug A doesn’t work for you, we would then cover Drug B.

You can review our Medicare drug list step therapy criteria (PDF) .

Yes. With thousands of drugs on the market and new ones introduced each year, we continually evaluate and update our drug list. This way, we can make sure you have access to prescriptions that are high in quality, safe and cost-effective.

• If we plan to remove drugs from the list or plan to add restrictions, we’ll let you know at least 30 days in advance. However, there may be times when we immediately replace a brand-name drug on our list with a new generic drug, or when we immediately replace an original biologic drug on our list with a new biosimilar drug. The new generic drug or new biosimilar drug will appear on the same cost-sharing tier (or lower) as the drug it’s replacing, with the same restrictions (or fewer). After the change is made, we’ll provide you with information about the specific change.
• If the FDA deems a drug to be unsafe or if a manufacturer takes a drug off the market, we remove it from our drug list immediately. If this happens, we’ll let you know and work with you to find a replacement.
• If you can’t find your drug on the list, contact Member Services to confirm it’s not covered. Our Member Services team always has the most up-to-date information.
• If we no longer cover your drug, start by talking with your doctor about other options from our drug list. If no alternatives are available, you or your prescriber can ask for an exception.

We’re required to furnish formulary change notices to you when available.

You can ask us to make an exception to our coverage rules. There are several types of exceptions you can ask for, including:

• Covering your drug if it isn’t on the drug list
• Waiving our coverage limits on your drug
• Asking us to cover your drug under a different cost-sharing tier

If we approve your request, your medicine will be covered even if it’s not on the drug list.

To request a paper copy of a formulary, please call the Member Services number on the back of your HealthPartners member ID card.