Pharmacy 101: Understanding costs and coverage for Medicare

Surprises are great—unless they’re on your prescription bill. Read on to learn about the Formulary, saving at the pharmacy, and more.

Cost, coverage, and savings information for Medicare Advantage members

Steps to take before going to the pharmacy

Take these 3 steps before going to the pharmacy to understand your prescription coverage, costs, and ways to save.

Step 1

Learn about the Formulary.

Keep reading this page to learn how to read the Formulary, then use it to find your medication and its tier.

Formulary - Medicare Advantage

Step 2

Check your summary of benefits.

Find your detailed coverage information such as co-pays or co-insurance by medication tier.

Summary of benefits

Step 3

Learn our important money-saving tips.

We’ll help you save time and money!

Top 3 money saving tips

What is the Formulary?

Formulary is the formal name for the list of medications covered by your Bright HealthCare plan. It is sometimes called a “Drug List.” Check out the FAQ section to learn how to navigate the Formulary.

Formulary FAQ

There are 3 columns on the Formulary document as shown below:

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1. Drug Name:

The name of the covered drug is located in the first column.

Generic drugs are identified in italicized, lower case letters. Typically, generic drugs work just as well and cost less than brand name drugs.

Brand names are indicated in BOLD, UPPERCASE LETTERS.

2. Drug Tier:

The second column tells you what tier your drug is on. For more information about tiers, see “What are tiers?” below.

3. Requirements/Limits:

The third column tells you if there are any special requirements that need to be followed to receive a drug. For more information about requirements, see “What are Special Requirements/Limits” below.

Visit the Bright HealthCare formulary:

Formulary - Medicare Advantage

The out-of-pocket cost of the drug is determined by its tier.

Tier 6 drugs are a special $0 class. For Tiers 1-5, the cost of the drug rises with the tier.

Tier 1 has the lowest out-of-pocket cost and Tier 5 has the highest.

Here is a breakdown of the type of drugs that fall on each tier:

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Cost share information:

Some tiers may have a copay, which is a set cost you will pay for your drug.

Some tiers may have coinsurance, which is the percentage of the drug cost you will pay.

In some cases, both copay and coinsurance won’t apply until your deductible is met.

Check your summary of benefits.

Find your detailed coverage information such as co-pays or co-insurance by medication tier.

Summary of benefits

Part B vs. Part D (BvD):

These drugs may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make this determination.

Excluded Drug (E):

Some drugs are not covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). Additionally, if you are receiving extra help to pay for your prescriptions, you will not get any extra help for these drugs.

Mail Order (MO):

These drugs are available via mail order.

Prior Authorization Type 1 (PA1):

Certain drugs require a prior authorization. This means you will need to get approval from Bright HealthCare before you fill your drug . If you do not get approval, the drug will not be covered.

Prior Authorization Type 2 (PA2):

FOR NEW STARTS ONLY. This means you will need to get approval from Bright HealthCare before you fill your drug for the first time. If you have previously received this drug through Bright HealthCare, you will not need approval.

Quantity Limits (QL):

For certain drugs, Bright HealthCare limits the amount of drug that we cover. For example, we may only cover 30 tablets or a 30-day supply of a certain drug.

Step Therapy Type 1 (ST1):

Bright HealthCare may require you to first try a certain drug to treat your medical condition before another drug will be covered. For example, if Drug A and Drug B both treat your medical condition, Bright HealthCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your provider may need to provide information to show you have tried Drug A, even if you have filled Drug A with Bright HealthCare before.

Step Therapy Type 2 (ST2):

Bright HealthCare may require you to first try a certain drug before another drug will be covered. If you have a history of filling the required drug with Bright HealthCare, you may not need to try other medications first.