4-minute readPublished 03/28/2024Updated 01:32 PM EST, 04/29/2025
Medicare Part D helps cover the cost of prescription drugs and is offered to everyone who qualifies for Medicare. Each Part D plan has a list of drugs that are covered by the plan, called a Drug Formulary (or "Drug Guide").
Here are some details to explain what a Medicare Part D formulary is and how it works.
In simple terms, a formulary is another name for a drug list. It’s an inventory of all the generic and brand-name prescription drugs covered by a Medicare drug plan. All Medicare drug plans generally must cover at least 2 drugs per drug category, but each individual plan can choose which drugs covered by Part D they will offer.1
Many plans arrange their list of covered drugs in different levels, called “tiers.” Drug tiers are a way for insurance providers to determine medicine costs.
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4-minute readPublished 03/28/2024Updated 01:32 PM EST, 04/29/2025
Medications covered by Medicare Part D are assigned to 1 of 5 tiers—from Tier 1 (generics) to Tier 5 (the highest cost drugs)—depending on their strength, type or purpose.
Your prescribed medications will be split into 3-Tier, 4-Tier or 5-Tier groupings according to your insurance plan.
If your plan features 3 tiers, Tier 1 includes generic drugs, such as low-cost preferred generics or general preferred generics. Tier 2 includes brand-name drugs, including preferred and non-preferred options. Tier 3 on a 3-Tier plan is for drugs with the highest costs.
If your part D coverage features 4 tiers, it includes Tiers 1, 2 and 3 and adds a 4th Tier for high-cost, mostly brand-name drugs.
If you have a 5-Tier plan, it will include Tiers 1 through 4 and adds a 5th Tier for the highest cost drugs, including most specialty medications used to treat rare, chronic, or complex health conditions.
In addition to at least 2 drugs per drug category, Part D drug plans must cover all drugs available in the following categories:2
Note: Part D plans must also cover most vaccines (e.g., shingles vaccine ) except for vaccines covered by Part B.2
Outside of the mandatory drugs required by Medicare, each Part D drug plan can choose what it covers. Some of the drugs typically not covered include:3
Note: Prescription drugs used for the above conditions may be covered if they’re prescribed to treat other conditions.3
If your specific drug is not on the formulary, there are several actions you can take.
In most cases, a similar drug to your specific drug should be available. If you or your prescriber believes none of the drugs on your plan’s formulary will work for your condition, you can request an exception.
A formulary exception asks a provider to cover a drug not currently on its drug list. It may also ask a provider to waive a step therapy drug requirement or to waive quantity or dosage limits on a drug. For more information, check out this information on exceptions
If your exception is denied, you can file an appeal to ask the provider to reconsider their decision. Also called a redetermination, the appeal can be filed by you, your representative , your doctor or a non-physician prescriber. Explore these details on Medicare Part D Coverage Redetermination to learn more.
If you’re unable to win the appeal, you must pay 100% of the costs out-of-pocket for all drugs considered “non-formulary.” Paying for these uncovered medications does not count towards your plan deductible or annual out-of-pocket max.
The best way to see if your prescription drugs are covered is to check the plan’s formulary. If you’re a Humana member with a drug plan, you can simply explore our list of covered drugs for Medicare .
Formulary prescriptions are included in a plan’s drug list and paid for by the plan. Non-formulary prescriptions are not included in the drug list and you pay 100% of the costs out of pocket. Non-formulary drugs can include over-the-counter medicines, experimental drugs or certain cosmetic or lifestyle medications.
No. All Part D plans generally must cover at least 2 drugs per drug category, but each individual plan can choose which drugs covered by Part D they will offer.
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4-minute readPublished 03/28/2024Updated 01:32 PM EST, 04/29/2025
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