Medicare prescription drug formulary (drug list) 

Medicare plans use drug tiers (or levels) to help members manage their costs. Drug tiers classify Part D drugs from lowest cost (starting at Tier 1) to highest cost. Plans can have different tiers for the drugs they cover.

Our Aetna® Medicare Part D drug tiers are:
 

• Tier 1 – Lower cost, preferred generic drugs
• Tier 2 – Slightly higher cost, includes generics 
• Tier 3 – Higher cost, includes preferred brand prescription drugs
• Tier 4 – Even higher cost brand name, includes nonpreferred prescription drugs
• Tier 5 – Highest cost prescription drugs, includes specialty drugs

No plan’s drug list covers all prescription drugs. If your drug is not on the drug list, you have three options: 

1. You may be able to get a temporary supply of the drug. (This is only for members in certain situations). To learn more, read this section: Can I get a temporary supply of my drug?
 

2. You can show the drug list to your doctor.  They may help you find a similar drug that is covered.

Want to know if your drug is covered? Check our drug list.
 

3. You and your doctor can ask us to make an exception for you and cover the drug.

We’ll need a statement from your prescriber or doctor to support your exception request.

Do you want to know how to ask for an exception? Go to your Evidence of Coverage and read the section called Step-by-step: How to ask for a coverage decision, including an exception.

To ask for coverage of a drug that’s not on the drug list is sometimes called asking for a formulary exception. In some cases, we make a formulary exception to cover a drug not on our drug list. If we do, you’ll need to pay the cost-share that applies to drugs in Tier 4 (nonpreferred drug).

Some drugs on the drug list have certain coverage rules you need to follow. These are rules made by a team of doctors and pharmacists. These rules are meant to help members use drugs safely and in a cost-effective manner.

The drug list will tell you if your drug has one of these rules, such as:

• Prior authorization (PA)
  Some drugs require you or your doctor to get PA. PA means you or your doctor have to get approval from the plan before you can get your prescription filled.
  
  
• Quantity limits
  For some drugs, there’s a limit on the amount of it you can fill within a certain time frame. These limits are based on the recommended dosage from the manufacturer and the Food and Drug Administration (FDA).

If you take more than the recommended amount, you’ll need to get PA (prior authorization). As an example, for some drugs, our plan will only provide up to 60 tablets for a 30-day prescription.

• Step therapy
  In some instances, you may have to try a certain drug to treat your medical condition, first, before we’ll cover another drug for your condition. 

For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. 

Want to know if your drug has one of these limits or rules? Check our drug list.

Asking for an exception for these coverage rules:

You and your doctor can ask us to make an exception to one of your plan’s coverage rules. This includes asking for an exception to a PA, quantity limit or step therapy rule. 

There are times you may be able to get a temporary supply of your prescription drug:

• You may be a member whose drug is no longer on our drug list, or it has new coverage rules.
• Or maybe you’re a new member and the drug you’re taking isn’t on our drug list, or it has coverage rules.

This is called a transition of coverage. If this is the case, you may be able to work with your doctor to get a temporary (transition) supply of the drug you take.

Learn more about how to get a temporary supply. You can review this sheet on our Transition of Coverage process with your doctor.

Medicare Part D plans cover at least two prescription drugs in most drug categories. They also cover all drugs in these categories: 

• Cancer treatment
• Antidepressants
• Antipsychotic medication
• Anticonvulsive treatment (for conditions that cause seizures)
• HIV/AIDS treatments
• Immunosuppressants

Federal law prohibits a Medicare Part D plan from covering certain types of drugs, including:
 

• Over-the-counter drugs (also called nonprescription drugs)
• Drugs when used for the treatment of anorexia, weight loss or weight gain
• Drugs when used for cosmetic or hair growth purposes
• Drugs when used for the relief of cough or cold symptoms
• Prescription vitamins and minerals (some exceptions for drugs like fluoride preparations)
• Drugs when used for the treatment of sexual or erectile dysfunction (ED)

Medicare Part D plans also cannot cover the following:
 

• Drugs that would be covered under Medicare Part A or Part B
• Drugs not approved by the U.S. Food and Drug Administration (FDA). Or drugs that are purchased outside the United States and its territories
• Off-label use of a drug. In many cases, if a drug is used in any way other than those indicated on a drug's label as approved by the Food and Drug Administration.

Want to know more? Get more facts on Part D drug coverage.