Medicare Prescription drug formulary

There are 5 tiers in the Medicare prescription drug tier list. These tiers represent cost categories for various Medicare Part D prescriptions.

• Tier 1 – Generic, low-cost drugs
• Tier 2 – Slightly higher copay and includes preferred brand name drugs
• Tier 3 – Higher copay and includes nonpreferred brand name drugs
• Tier 4 – Even higher copay and includes most nonpreferred drugs (generic and brand name)
• Tier 5 – Highest out-of-pocket costs and includes most specialty medications  

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

1. You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). For more information about temporary supplies, see the section below called Am I eligible to receive a temporary supply of my drug?

2. You can show the formulary to your doctor for assistance finding a similar drug that is covered.

Check our prescription drug formularies (drug lists)

See if your drug is covered in our plans

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

Your plan will require a statement from your prescriber or physician to support your exception request.

For information on how to ask for an exception, refer to our Evidence of Coverage and look for the section called Step-by-step: How to ask for a coverage decision, including an exception.

Asking for coverage of a drug that is not on the formulary (drug list) is sometimes called asking for a formulary exception. In certain cases we make a formulary exception to cover a drug not on our formulary. If we do, you will need to pay the cost-share that applies to drugs in Tier 4 (Non-preferred drug).

Some drugs on the formulary (drug list) have certain coverage rules you need to follow. These are special requirements developed by a team of doctors and pharmacists. Their purpose is to help members use drugs safely and in a cost-effective manner.

The formulary will tell you if your drug has one of these requirements, such as:

• Prior authorization
  Some drugs require you or your physician to get prior authorization. You must get approval from the plan before you can get your prescription filled.
  
  
• Quantity limits
  For certain drugs, there’s a limit on the amount of it you can fill within a certain timeframe. Quantity limits are based on the manufacturer’s and the Food and Drug Administration’s (FDA) recommended dosage.
  

If you take more than the recommended amount, you will need to request a Prior Authorization (described above). For example, our plan provides up to 60 tablets per 30-day prescription for some drugs.
 

• Step therapy
  In some instances, the plan requires you to first try certain drugs to treat your medical condition before it will 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.

Check our prescription drug formularies (drug lists)

See if your drug has one of these limits or requirements.

View now

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

Aetna® Medicare has a transition policy for prescription drugs you may be taking that aren't on our formulary (drug list) or are subject to new requirements. Under this policy, you can receive a temporary supply of the drug. This policy enables you to work with your doctor to either transition to a new drug or request an exception to continue your current drug.

Use the link below to learn about our transition process to see if you’re eligible for a temporary supply of medication.

Details about our transition process

Medicare Part D plans cover at least two prescription drugs in most drug categories, as well as all drugs in the following 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)

In addition, Medicare Part D plans are unable to 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 that are purchased outside the United States and its territories
• Off-label use, in many cases, in which a drug is used in any way other than those indicated on a drug's label as approved by the Food and Drug Administration

For more information on formularies, drug tiers and prescriptions, please visit our Unpacking Medicare prescription drug coverage page.