In my time as an insurance agent and trainer, one of the most confusing and frustrating parts of medicare has been the drug portion, known as Part D in most cases.
We are going to cover a few terms that will help you understand and then talk about a few ways that can help you save money on your prescriptions.
Formulary: A list of drugs that are covered under the plan.
All plans are required to cover at least one prescription drug in each category. What this means for you is that the plan will always cover at least one drug for your condition. This does not mean they will cover the drug that you are currently taking, however.
Drug Tiers: What level the drug falls into.
All plans place their covered drugs into tiers. Most plans have 5 drug tiers, however, some have additional tiers for drugs for certain conditions such as diabetes to help keep the costs lower for members on their plans.
Tier 1 - This is usually your preferred generics; these are generally the lowest cost and most common prescriptions
Tier 2 - Tier2 is also known as the non-preferred generics; similar to tier 1 these are usually lower cost and common prescriptions and they will usually be the second-lowest costing in your plan.
Tier 3 - This is the start of your brand name prescriptions. These are typically the most common and least expensive brand name prescriptions.
Tier 4 - Tier 4 encompasses most of the remainder of brand-name drugs.
Tier 5 - This is referred to as the specialty tier; these are high-cost drugs and on most plans will be covered initially at 33% of the cost of the drug. Due to the high cost of these prescriptions, many people will fall into the coverage gap in the first few months of starting the plan.
Extra Help: A program that is based on your income that will help lower the cost of your prescriptions.
The Extra Help Program, also known as LIS or Low Income Subsidy, is a federal program that you can sign up for. Your Income is used to determine which level of extra help you qualify for. If approved you could have significantly lower drug costs.
State Pharmaceutical Assistance Programs: Each state has an assistance program, also known as SPAP, with different criteria than the Extra Help Program.
These programs are based on income as well, but the income by the state could be higher than the federal Extra Help program, meaning if you do not qualify for the Extra Help program you might be able to still participate in the state program.
What if my prescription is not covered?
If you are taking a drug that is not covered, or are on a plan and your doctor prescribes a drug that is not covered you have a few options:
Step Therapy - This is a function in which the plan requires you to try other prescriptions that are on the formulary, usually less expensive, to see if it will work for you. If you go through step therapy and no other drug works then your plan MAY, it's not a guarantee, grant an exception and cover your prescription
Formulary Exception - Your doctor can fill out the plans form to ask for a formulary exception. Then plan then will decide if they will allow the exception and cover the prescription.
GoodRx.com - GoodRX.com is a great resource that provides coupons to lower your prescription drugs for drugs that may not be covered by your plan. In some cases, my clients have used the GoodRx coupon to pick up their prescription because it was cheaper with the coupon than with the prescription plan. They also have information on drug manufacturers in case you have a really expensive prescription, many manufacturers also have plans that will help you offset costs.
You can see how the drug plans in your area can work for you on our website. www.E-AdviseInsurance.com, or you can give us a call at 727-678-1505
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