Refer to your plan’s formulary for covered drugs

Your Blue MedicareRx (PDP) formulary lists the drugs covered by your plan. We organized it in alphabetical order by drug category and the condition treated. For easy reference, you will also find an alphabetical list by drug name near the back of the book with page numbers listed. Included for each drug are the drug name, covered dosages, the tier designation that determines your copay/coinsurance for the drug, and any requirements or limits related to coverage.

drug details example, showing: drug category, drug name, drug tier and requirements/limits

Drugs are grouped by category based on the condition they treat. Within each category, drugs are listed alphabetically. If the drug your doctor prescribes is not listed, consider discussing other drugs covered by your plan that you and your doctor believe will be an effective treatment for your condition. Other covered options may be less expensive. If you and your doctor determine that no covered option is appropriate for your treatment, you may request a coverage determination.

Drug Tiers

The tier assigned to each covered drug determines your share of the cost of the drug - essentially what you will pay out-of-pocket. Drugs in some tiers have a copay, which means you pay one flat price for all drugs in that tier. Some will have a coinsurance, which means you pay a specific percentage of the drug’s list price. Your out-of-pocket costs may be higher or lower, depending on which pharmacy you use and your current stage of Medicare Part D coverage. Refer to your plan’s Evidence of Coverage, or use the Drug Pricing Tool to determine your out-of-pocket costs for your prescriptions.

Tier 1 Preferred Generic
Certain generic drugs that are available at the lowest copayment
Tier 2 Generic
Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs
Tier 3 Preferred Brand
Many common brand name drugs and some higher cost generic drugs, many of which may have lower cost options available on Tier 1 or Tier 2
Tier 4 Non-Preferred Drug
Higher cost generic and non-preferred drugs, many of which may have lower cost options available on Tier 1, Tier 2 or Tier 3
Tier 5 Specialty
Unique and/or very high cost brand and some generic drugs, of which you pay a percentage of the total drug cost; may require special handling and/or close monitoring

Drug Requirements/Limits

The information in the Requirements/Limits column tells you if there are any special requirements associated with coverage for your drug:

PA – Prior Authorization You will need to obtain approval before you fill your prescription
QL – Quantity Limit There is a limit to the amount of the drug the plan will cover with each prescription filled
ST – Step Therapy You may be required to try an alternative drug before this drug is covered.
NMO – No Mail Order This drug is not available from mail-order pharmacies
LA – Limited Access This prescription may be available only at certain pharmacies
B/D – Covered Under Medicare B or D This drug may be covered under Medicare Part B or Part D, depending on the circumstances

If you or your doctor believes you should be granted an exception to these requirements or limitations based on your condition, you may request a coverage determination.

Learn about Medicare coverage stages