Answers to ALL Your Medicare Questions

Drug Formularies and Picking a Plan

Picking the right Prescription Drug Plan is a bit like picking a place to go for a vacation other than with a vacation the destination choice you make is about what you want to do. With a drug plan the choice is about what you need to take.

With a vacation, you may get there and discover there are new things to do you hadn’t even known about when you booked your trip. It’s the same thing with a prescription drug plan. While being on the plan, your drug needs could change, such as by adding a new drug or substituting one drug for another. Therefore, something important to know right out of the gate: 

Your Drug Plan is Not Cast In Cement

Each year you can use the Annual Enrollment Period from October 15 to December 7 to change to a different drug plan for the following year. This way, if your drugs change and the plan you are on is no longer a good fit with your drug list, you won’t be stuck with it for too long. Each year you can make a change to a plan that works better for you with your new plan taking effect on January 1.

Not only can your list of drugs change but drug plans can change their formulary so that a drug covered this year may be dropped from coverage next year or could be raised to a higher tier next year costing you more in copays. The good news is that just as you can only change your drug plan once a year to begin fresh on January 1, likewise the only time a Prescription Drug Plan can change their drug formulary, impacting you, is once a year on January 1. If a drug you are on is covered well when you go on the plan you can be assured it will be covered the same the remainder of the year. 

Drug Plan Can Matter A Lot Or Sometimes Not At All

We all know someone who is in their 80s or 90s and the strongest drug they have ever taken in their life is a Flintstone vitamin. For many people entering Medicare at age 65, how their plan covers prescription drugs is the least important part of Medicare for them.

For other people, whether they are getting their prescription drug coverage through a Medicare Advantage plan or through a stand-alone Prescription Drug Plan, how their drugs are covered is at the top of the heap of what is important to them in selecting their plan.

With the lucky first group of people who only take Tier 1 and 2 generic drugs, or no drugs at all, their copays in a year are going to be next to nothing. Whether they pay $1 out of pocket with Plan A or $3 with Plan B isn’t going to make much of a dent. For other people, the difference between one plan and another could amount to hundreds if not thousands of dollars in copays every year. These are the people who often also most need the expertise of a skilled agent in helping them formulate their drugs in selecting a plan. 

How Plans Formulate

Every drug plan, whether it’s part of a Medicare Advantage plan or a stand-alone Prescription Drug plan, is required to have a minimum of two medications from each therapeutic category or class in the formulary. The exception is if there are only two drugs in the class in which case they are only required to cover one of those two.

Each year every carrier must provide a list of all the drugs they cover and the tiers that they have placed them into, called a Formulary.

It would be easy for us all if every plan had the same formulary but Medicare plans do not make it easy. Formularies are vastly different from one carrier such as Aetna to another such as Humana. But it gets even more complicated because a carrier will often have several plans, each with a different formulary. A drug that you take could be Tier1 in Plan X and Tier 2 or even not in formulary at all in Plan Z.

Just as some restaurants serve Coke and other restaurants choose Pepsi, some plans may choose to make one drug their preferred choice in a class and another plan will choose a different drug. This will have obvious consequences in the number of your copays from one plan to another. Because of this, many people will have the important next step: Formulating the drugs they take and comparing how they are tiered in different plans.

Formulating Your Drugs: WE  Will Do It For You

Here is something that you have probably noticed: Most prescription drugs have very complicated names. We have to be chemists to understand what the name means or national spelling bee champions to come close to spelling it. It is as though none of us are even supposed to figure out what we are taking. The drug companies must have figured out that the more mystery they create about what we are taking then the less we will question our doctors about why we need the drug in the first place or moan to the pharmacist about how much it costs.

Having said that, there are two important aspects to all these drugs we’re taking with names that are often a mile long. Firstly, if a drug is working for us then we want to keep taking it. We do not want our drug plan telling us that we can’t. Secondly, we do care about the cost. If each tiny little pill costs more than a meal at our favorite restaurant we wonder how that can be. We’re just not happy about the idea of one pill and a lobster having the same cost.

It will take research to know if the prescriptions you take are even covered by a given plan, what the copay is, and if there are restrictions on how many refills you can have. You might be very good at doing this type of research for yourself and if you are then I will offer you a great SELF-SERVICE resource website to do so at

Many people, however, prefer FULL SERVICE when it comes to such a complicated task as formulating their drugs. This is where we at MedicareIGetIt have a great deal of experience and would be happy to formulate your drugs for you. We will then give you our recommendations as to which plans formulate your drugs the best. This is a FREE Service we are happy to provide.

Formulating Your Drugs: Or, Do It Yourself

Here’s an interesting observation that may or may not have anything to do with formulating your drugs. My grandson recently had his 8th birthday and I asked him what he wanted, which if you happen to know just about any 8-year-old these days was a Lego set. The one he picked was a Navy ship complete with a well-armed helicopter. It came in 776 pieces he put together himself. If you have ever bought a Lego set, you know they are not cheap. This one cost $150. When he had it built and I took a look at the finished ship I realized that if it had come as a pre- assembled toy it would have cost under $20. The point is that some people like doing it themselves, and will even pay an extra $130 for the fun of doing so.

In your case, if you want to do formulating your prescriptions yourself, it won’t cost you a thing. We have a dedicated platform for clients where you can do just that. The link to it is below:


Once you are on the site just put in your Zip Code and Click “See Plans and Prices.” Skip the popup that comes up.

Next, click to enter your drugs.

Next, add in all your prescription drugs, typing the name for each drug that you want to research how it's covered by various plans.



After you have your drugs added in you will be able to see how they are formulated and see an approximation of what your drug copay costs will be. You can read the details by clicking any plan you are interested in. Once you do so you will see a tab that says “Drug Cost Details”. When you click this tab you will see a breakdown of which tier each of your drugs are in and you’ll be able to get your copay costs, even broken down by the months of the year. I believe you’ll find a very handy tool for prescription drug formulating do-it-yourselfers.

Factoring Drug Costs Into Picking a Plan 

I mentioned my Television Rule earlier: If a drug is advertised on TV it means that when you see its cost, be prepared to say, “Wow!” And that’s not the good, “Wow!” Take Humira as our example. Humira’s TV spots feature the world’s second most famous golfer, Phil Mickelson. Phil suffers from rheumatoid arthritis in real life and according to the commercial Humira relieves his symptoms.

As I also mentioned earlier, Humira costs $1,100 a month at a minimum. On most plans, Humira is a Tier 5 drug, but it could also be a Tier 4 on other plans. If it is a Tier 5 your copay will likely be 33% or over $350 a month. If it is a Tier 4 your copay will drop to $100 or below. The difference could add up to an extra $1,000 during the time you are in the $4,130 Initial Coverage Phase.

Now, $1,000 might not mean very much to Phil Mickelson who is reported to earn 37 million dollars a year from endorsement alone, which includes his endorsement of Humira. But for most of the rest of us, $1,000 is not “it clogs up our wallet” money.

The difference between a drug being Tier 1 with one plan and Tier 2 with another will increase your copays often by $5 or more. A jump from Tier 2 where copays are usually under $10 to Tier 3 where copays are in the $45 neighborhood, could lead to an extra $400 in annual copays. The next leap, from Tier 3 to Tier 4, doubles your copay from around $45 to $90 to $100.

This is, of course, why it is important to formulate your drugs, particularly when they are in Tier 3 and above category. It could make a big difference in how much goes onto your MasterCard when you get your prescriptions. And aren’t there better things that we all want to run up our credit card balances for, than tiny little pills?

There is another reason why it could be important to formulate as well: Because not every drug we take is in every drug plan’s formulary. Sometimes you will find a drug you take is in one plan’s formulary but not in others which could be a major factor in your plan choice. Ideally, we want to select a plan where all the drugs we take are in formulary.

An Important Thing To Know About: Exceptions 

We discussed earlier how plans only need to have a minimum of two drugs in any therapeutic category, much as restaurants only need to serve either Coke or Pepsi. When it comes to colas most soda drinkers have a preference between Coke or Pepsi, but can live with whatever is served. After all, it’s only a cola.

The drugs we take for our medical conditions are far more important to our wellbeing than which soda is on tap. Carrying the soft drink metaphor forward, not all of us can manage the same if our plan chooses to have Coke in their formulary but Pepsi works better for treating our condition. And what if it is Root Beer we need instead of a cola, and there isn’t a plan that offers Root Beer?

Soft drink metaphors aside, the fact that there may be several different drugs in a therapeutic category does not mean that all of these drugs will work equally for every person. Your body might simply respond better to one drug over another or the side effects might be severe with the drug that is in formulary which might not be the case with a drug that isn’t in formulary. Some people also don’t do as well with the generic drug versions as they do on the name brands.

For these reasons, Medicare provides an option so that if it is Pepsi you need and the restaurant serves Coke, you can get Pepsi. It is called an “Exception.”

Your doctor (or you can do it as well) can submit a request for a particular drug to be brought into the formulary for you on the basis that the drug is needed and the drug choices that are in formulary will not be as effective or will cause adverse reactions. Your Drug Plan will have 3 days to respond to an exception request or 24 hours if it’s an expedited (emergency) request.

Your plan will either agree that it is medically necessary in which case the exception will be granted or not. If the request is rejected you can file a request for redetermination (an appeal).

Another common basis for submitting “Exceptions” is if a drug is in formulary but the tier is too high. Let’s go back to our Humira example. If you happen to have rheumatoid arthritis one of the prescriptions you might take for your symptoms is Rheumatrex and with an $11 cost for 30 pills, drug plans are willing to help you pay for it and happily make it a Tier 1 or 2 choice. It sure beats them paying their share of the $1,100 Humira cost.

Now let’s say that Rheumatrex just doesn’t cut it for you and Humira is the only choice that works. In this instance, you can file for an exception asking that Humira be brought down to the Tier level of Rheumatrex for you. Medicare refers to this as a Tiering Exception which is a request to obtain a non-preferred drug at the lower cost-sharing terms of the preferred drug choices.

For more information about Exceptions refer to the Medicare website:


How To File For An Exception 


I know what you are thinking, “More paperwork.” And, don’t we all enjoy that?  But when it comes to saving money it could well be worth the trouble. The good news is though that your Prescription Drug Plan can’t simply ignore your request; they have to follow Medicare’s rules in being responsive.

In fact, once a plan receives your formulary change request they must respond to it with a decision within 72 hours or 24 hours if it is an emergency request. If the decision is unfavorable the decision will also contain information for filing an appeal.  

Your exception request can be filed by your doctor or you can easily make the request on your own. Your plan carrier will have a form for submitting your exception request which you can look up on your Member Portal (such as your Humana, Aetna, United or WellCare portal). Information on creating a member portal will be part of your member welcome package.  You can also make the request by writing a letter, instead of using the form, or even by way of a verbal request.

If you can’t find the forms or information you need in your portal then call your plan’s customer service number (the number on the back of your card) for plan specific forms or information.

Your request is simply a matter of laying out the medical facts. For instance telling them how you have tried the drugs that are in their formulary and they gave you side effects that the drug you are requesting does not give you. Include any supporting information which you can provide. Think of the process as being like going before Judge Judy and you want to make your best case.   



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