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How can I tell if my medicine is covered by your drug plan?

Each Medicare drug plan has its own list of covered drugs. This is called a formulary. Our formulary lists the drugs covered by our Medicare plans. You can search the list by the name of your medication.

When we make our drug list, our team of pharmacists and doctors reviews information on new medicine covered by the U.S. Food and Drug Administration. The experts compare it to the meds that are already on the list. The goal? To make sure our drug list has the safest and most effective medicine.

What are the different Medicare drug tiers?

When you look at the drug list, you may notice that our drug plan places drugs into different tiers. Drugs in each tier have a different cost. Knowing what tier your drug is on can help you predict how much it’ll cost. Drugs on lower tiers generally cost less than drugs on higher tiers:

  • Tier 1: Preferred generic drugs
  • Tier 2: Generic drugs
  • Tier 3: Preferred brand drugs
  • Tier 4: Non-preferred drugs
  • Tier 5: Specialty drugs

Minnesota Senior Health Options (MSHO) has one tier, but your copay depends on whether it’s a generic or a brand name drug.

What’s the difference between generic, brand-name and specialty medicine?

Both prescription medicine and over-the-counter medicine can have brand name and generic versions. Generic and brand-name drugs use the same active ingredients, and they have the same dosage, strength, instructions and use. In fact, the FDA requires generic drugs to be as effective as brand-name drugs.

The biggest differences between generic and brand-name drugs are what they look like and the cost. Trademark laws require generic drugs to look different than the brand-name versions. Generic drugs typically cost at least $100 less than the brand-name versions.

Specialty drugs tend to be high-cost drugs. They are often self-injected and treat complex or rare conditions.

How much will I pay for my medicine?

It depends. If your plan has a deductible, you’ll need to pay the full cost of each medicine until you’ve met your deductible. After that, HealthPartners will pay part of the cost, and you’ll pay part of the cost. The tier your drug is in determines the amount you’ll pay.

If you qualify, Medicare could pay up to 75 percent or more of your drug costs. This could include monthly prescription drug premiums, annual deductibles, and co-insurance.

Finally, the amount you pay can depend on where you fill your prescriptions. Cost can be different at a network pharmacy, an out-of-network pharmacy or a mail order pharmacy. Learn more about pharmacy options or find a pharmacy.

Are there limits on drug coverage?

Sometimes. Some covered drugs may have extra requirements or limits, including:

  • Prior authorization: We may require prior authorization for certain drugs, even if they’re on the drug list. This means that you’ll need to get approval from HealthPartners before you fill your prescription. If you don’t get prior approval, your drug may not be covered.
  • Quantity limits: With some drugs, there are limits on the amount of drugs we cover. For example, this limit may be in the form of only covering a 30-day supply. There may also be limits on the number of tablets for a specific prescription that we’ll cover in one day.
  • Step therapy: In some situations, you may be required to try another drug before we cover the drug you’re requesting. For example, if Drug A and Drug B both treat your medical condition, HealthPartners may not cover Drug B until you try Drug A first. If Drug A doesn’t work for you, HealthPartners would then cover Drug B.

Can the drug list change?

Yes. There are thousands of drugs on the market, and new ones are added all the time. To make sure you get the highest quality, safest and most cost-effective drugs, we continually update our drug list. That means we may need to add it to our drug list.

If we plan to remove drugs from the list or plan to add restrictions, we’ll let you know at least 60 days in advance. If you request a refill of a discontinued drug, you can receive a 60-day supply.

If the FDA deems a drug to be unsafe, or if the drug manufacturer removes the drug from the market, we take it off our list immediately. If that happens, we’ll let you know, and we’ll work with you to find a replacement.

If we no longer cover your drug, please talk with your doctor about other options.

If you can’t find your drug on the list, call Member Services to confirm that it’s not covered. Member Services always has the most up-to-date information.

Ask Member Services for a printed drug list. Then, bring it to your doctor and ask him or her to prescribe a similar drug that HealthPartners covers. If nothing is available, you can ask for an exception.

How do I ask for an exception?

You can ask HealthPartners to make an exception to our coverage rules. There are several types of exceptions you can ask us to make, including:

  • Covering your drug if it isn’t on the drug list
  • Waiving our coverage limits on your drug
  • Asking us to cover your drug under a different cost-sharing tier

If the request is approved, your medicine will be covered, even if it’s not on the drug list. In most situations, we review and respond to requests on the way we receive them. Your doctor can use this exception request form or contact Member Services to request your exception.

What if I still have more questions?

Not seeing the answer to your question? We can help. Call Member Services or review your plan details to learn more.

Last updated October 2019

H2422_118314 Approved

H2462 H4882_118314 Accepted

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