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.
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.
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.
Check your summary of benefits.
Find your detailed coverage information such as co-pays or co-insurance by medication tier.
Learn our important money-saving tips*.
We’ll help you save time and money!
*Benefits vary by plan. Please consult your plan documents or contact Member Services about your plan benefits.
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.
There are 3 columns on the Formulary document as shown below:
1. Drug Name:
The name of the covered drug is located in the first column.
Generic drugs are identified in italicized. Typically, generic drugs work just as well and cost less than brand name drugs.
Brand names are indicated in UPPER CASE LETTERS.
2. Drug Tier:
The second column tells you what tier your drug is on. For more information about tiers, expand below.
3. Coverage Requirements and 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, expand below.
Visit the Bright HealthCare formulary:
- Use the index at the end of the document:
All drugs on the formulary are listed in alphabetical order and display the corresponding page number.
- Look up by Medical Condition Categories:
Drugs are grouped into medical condition categories based on what they are used to treat. The categories are identified in black on the formulary. This example shows drugs used to treat asthma and can be found under Respiratory Therapy Agents.
The Formulary is divided into tiers based on the type of drug. The out-of-pocket cost of the drug is determined by its tier.
The higher the tier, the higher the cost of the drug.
Tier 6 drugs are a special low-cost class. These drugs along with Tier 1 will be $0 for all plans. 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:
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 (after meeting your deductible).
In some cases, both copay and coinsurance won’t apply until your deductible is met.
To find your actual out-of-pocket costs by tier, refer to your Summary of benefits
Part B vs. Part D (BvD):
These drugs may be covered under Medicare Part B or D depending upon the circumstance. Information by 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 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 (PA):
Certain drugs require a prior authorization. This means you will need to get approval from Bright HealthCare before you fill your prescription. If you do not get approval, the drug will not be covered.
Prior Authorization Type 2 (PA NSO):
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 the drug that is covered. For example, Bright HealthCare may only cover 30 tablets for 30 days.
Step Therapy (ST):
Bright HealthCare may require you to try a certain drug 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, Bright HealthCare will then cover Drug B.
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.
Limited Access Drugs (LA):
This drug may only be available to certain pharmacies. For more information, you can call member services at (833) 726-0667, 24 hours/365 days. TTY/TDD dial 711.
Gap Coverage (GC):
Bright Healthcare provides coverage of this drug in the coverage gap, also known as the donut hole.
Non-Mail Order Drug (NM):
Medications that are not available via mail order.
Non-Extended Days’ Supply (NDS):
Bright HealthCare limits certain drugs that is covered within a specific time frame.
Capped Benefit (CB):
This drug is a part of capped benefit.
Select Insulins (SI):
This insulin is part of the Senior Savings Model Program which lowers the cost. Please refer to our Evidence of Coverage or contact member services for more information (833) 726-0667, 24 hours/365 days. TTY/TDD dial 711.