Medicare, Social Security, and Insurance

5/8/2017 | By Seniors Guide Staff

Understanding how Prescription Drug Plans (PDP) work can save a lot of money and grief by picking the plan that covers all your medications at the lowest cost. It is a common misconception amongst Medicare recipients that a higher premium means better coverage, but what determines which PDP would be best is the plan’s formulary and where they place your medications on the tier list within that formulary.

A formulary is basically a list of medications that any given plan will cover and pay for. Every PDP has a formulary and every formulary is different. This means the most important part of finding the best plan is making sure that all medications taken are on that plan’s formulary. Another factor to be aware of is the more medications a consumer takes, the more difficult it will be to find a plan that covers all the medications.

Once narrowing down to PDPs that have all prescribed medications on their formularies, the next step is finding the plan that covers the medications at the lowest cost. What determines this is the tier level in which the plan places each medication in. There are five tiers, and the lower the tier, the lower the cost of that medication.

So, what do you do if your doctor prescribes a medication that isn’t covered under your plan’s formulary? You have a few options in that scenario. The simplest solution would be to find a medication that is on your plan’s formulary that is like the one prescribed. A common medication in which this scenario applies is insulin. There are many brands of insulin, and it is unlikely that a drug plan will cover all the brands. Generally, most plans cover at least one brand of different types of medications.

Switching brands can work with some medications, but it is not guaranteed. Sometimes a consumer must take a specific brand because it is the only one that is effective or other brands have adverse side effects. In this case, a consumer can ask their doctor to request an exception for the medication. This is not guaranteed to work, but it is the only way to get a medication covered if you are unable to change your plan outside of the annual Open Enrollment Period. The doctor would have to send a written request to the plan explaining why this medication is medically necessary and why no other medication can be used.

When deciding which Medicare PDP to enroll in, always remember that finding a plan with a formulary containing all the medications prescribed at the lowest tier and cost is the most important thing. Premiums and deductibles should only be considered after the plans with adequate formularies and tiers have been found.

The Seniors’ Health Insurance Information Program (SHIIP) is a division of the North Carolina Department of Insurance, and can help answer any questions about Medicare PDP costs and coverage over the phone or in person. Trained SHIIP counselors are available for free, unbiased counseling appointments in all 100 North Carolina counties. For more information, contact SHIIP at 1-855-408-1212 or visit

Seniors Guide Staff

Seniors Guide has been addressing traditional topics and upcoming trends in the senior living industry since 1999. We strive to educate seniors and their loved ones in an approachable manner, and aim to provide them with the right information to make the best decisions possible.

Seniors Guide Staff