Medicare Part D: What Drugs Are Covered - The Formulary

All plans contain a Formulary which is a list of all of the medications available under the plan.

A formulary must cover:

• At least two drugs in each class of drugs used to treat the same medical condition.
• Nearly all drugs used in the following classes:
  • Antidepressants (for depression)
  • Antipsychotics (for mental psychoses)
  • Anticonvulsants
  • Antiretrovirals (for HIV/AIDS)
  • Anticancer

When checking to be sure your drug is on the formulary, contact the carrier covers the exact dosage as well as the form (such as pill, liquid or patch) of each medication that you take.

The following drugs are excluded from Medicare coverage by law: 

• Some drugs used for anti-anxiety treatments. For example: barbiturates and benzodiazepines such as Valium)
• Drugs used for cosmetic uses
• Fertility drugs
• Over-the-counter drugs
• Drugs used with for weight problems

Companies can change formularies whenever they want during the course of a year provided you are given 60 days prior notice. There is an exception: if you have been taking a drug for a while, and do not stop taking it, the plan must cover it even if it changes the formulary.

Plans can also move drugs to a different copay tier at any time during the plan year. You must give you 60 days' notice before doing the plan can make the change. If a change is made, you can request an exception.

Companies must post a current, shortened list of covered drugs on their web site. The list must be updated at least monthly. While companies are not required to confirm coverage of specific drugs over the telephone, they must mail their abridged formulary to anyone who asks for it. Formulary information must indicate if the plan places restrictions on coverage of particular drugs such as prior authorization, step therapy (whether you have to try a less expensive drug first), and dosage limits. Only current members have the right to request a copy of the entire formulary (which is normally sent by mail.)

If you decide that a plan no longer works for you, you can change plans once a year without penalty between November 15 and December 31. The change takes effect January 1 of the next year.

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