How do I read a drug list?
Who is this for?
If you need to know whether a Medicare Advantage plan covers your prescription, learning to read a drug list, also called a formulary, will help.
The best way to avoid surprises at the pharmacy is to know what your plan covers. You can find that information in your plan's formulary: it's list of covered drugs.
When you open it up and look for a drug, you'll see something like this.
|Drug Name||Drug Tier||Notes|
|TAMIFLU CAPS 45MG, 75MG||3||QL (50 per 180 days)|
First column: What's it called?
The first step to finding your prescription in a formulary is knowing its name. You can get that information from your prescription, doctor's office or pharmacy.
Then you can look it up in your formulary's index. Drugs are listed there alphabetically.
If you're reading a PDF of your formulary online, you can quickly find your drug using these shortcuts. For Windows, type Ctrl+F. If you're a Mac user, type Command+F. A small window will pop up on the screen. Enter the drug you’re looking for, and you'll see all the places it shows up.
Second column: What will you pay?
In our plan formularies, you'll notice in the first column drug names are either capitals or italic type. In general, these mean:
- Italic = generic drugs that'll have lower copays and costs
- Capitals = brand name drugs that'll have higher copays and costs
The second column, drug tier, also gives you important information about cost. Although what you pay depends on which plan you have, here's what drug tiers tell you.
- Tier 1 Preferred Generics: Commonly prescribed generic versions of brand name drugs with the lowest copay.
- Tier 2 Generics: Generic drugs with a higher copay that still save you money over the brand name versions.
- Tier 3 Preferred Brand: Brand name drugs with a lower copay or cost than drugs in Tier 4.
- Tier 4 Nonpreferred Drugs: Many of these drugs have lower-cost alternatives available in other tiers, so your copay or cost will be higher.
- Tier 5 Specialty: These drugs require special handling or administration, so they tend to be the most expensive.
Third column: What do you need to do to fill your prescription?
The notes in column three tell you about any special rules for your prescription. They're especially important, because if you don't follow them, your plan might not pay its share of the cost.
In the example above, QL stands for quantity limits. It tells you that your plan will only pay for 50 pills every 180 days. Other common letters you'll see in column three include:
- ST = Step therapy, which means trying lower cost drugs before your plan will pay for more expensive options.
- PA = Prior authorization, which means your plan needs to approve the prescription before you fill it.
You'll find all these abbreviations and what they mean listed at the bottom of the page of your plan's drug list.