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MAC & Bronchiectasis | Last Active: 7 hours ago | Replies (161)
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Level or Tier 1: Preferred, low-cost generic drugs
Level or Tier 2: Nonpreferred and low-cost generic drugs
Level or Tier 3: Preferred brand-name and some higher-cost generic drugs
Level or Tier 4: Nonpreferred brand-name drugs and some nonpreferred, highest-cost generic drugs
Level or Tier 5: Highest-cost drugs including most specialty medications
If the drug is listed with a tier in your plan, it is not covered. Sometimes an appeal can get coverage. An organization like NJH has a better chance of getting an appeal approved.
Replies to "Level or Tier 1: Preferred, low-cost generic drugs Level or Tier 2: Nonpreferred and low-cost generic..."
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I think you meant to say if a drug is NOT listed? Even then , Tier 4 & 5 drug approvals are a "crap shoot" for us, depending on who is the Pharmacy Benefit Manager (PMB). This year we were fortunately able to switch away from the plan that gave us endless grief last year, even on some Tier 3 medications. Last year I spent over 150 hours on prior approvals, appeals, and more for Tier 3 & 4 medications, this year maybe 20 hours?
Another thing about formularies - the listing is not the "whole story" each medication may also have codes which indicate limits on dispensing, whether "step up" therapy is required (trying other cheaper meds first), and whether prior approval is required.
@irenea8 If I was starting this process, I would look for an independent (not tied to one insurance provider) Medicare consultant to walk me through this.