PharmSurance Field Guide
How to Read
a Drug Formulary
Every Medicare drug plan has its own covered drug list called a formulary — with tiers and rules that vary between plans. Your advisor checks it for you, but knowing how it works puts you in the driver's seat.

Your PharmSurance advisor reviews how your medications are treated under each plan before making any recommendation — but the more you understand about how this works, the better questions you can ask and the more confident you'll feel in your final choice.

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What Is a Formulary?
The basics
In plain terms

A formulary is a list of drugs a plan covers — organized into tiers that determine how much you pay for each medication.

The five tiers (typical)
  • Tier 1: Preferred generics — generally the lowest cost tier
  • Tier 2: Non-preferred generics — a step up from Tier 1
  • Tier 3: Preferred brand-name drugs — a further step up
  • Tier 4: Non-preferred brand-name drugs — higher still
  • Tier 5: Specialty drugs — generally the highest-cost tier
  • If your drug is not covered under a plan's list, you may pay full retail price
Restrictions to Watch For
Prior authorization, step therapy, quantity limits
Why this catches people off guard

Even if your drug is on the formulary, there may be rules attached that limit or delay access. Knowing these upfront prevents surprises.

Common restrictions
  • Prior Authorization (PA): the plan must approve the drug before covering it — requires paperwork from your doctor
  • Step Therapy (ST): you must try a cheaper drug first before the plan covers the one your doctor prescribed
  • Quantity Limits (QL): the plan limits how much of a drug it covers per fill or per month
  • These restrictions vary by plan — the same drug may have no restrictions on one plan and full PA on another
How to Check Your Drugs
Before you enroll
The pharmacy professional advantage

Your advisor checks your specific medications against each plan's formulary before recommending anything — and their pharmacy background means they're reading the formulary the same way a dispensing pharmacist would, not just checking a box.

What to share with your advisor — and verify together
  • A list of all your current medications — name, dose, and how often
  • Note which are brand-name vs. generic
  • Note any specialty medications or injectables
  • Mention medications you take seasonally or occasionally
  • Mention any upcoming medication changes your doctor has discussed
What changes every year
  • Formularies can change at the start of each plan year — drugs can move tiers or be removed entirely
  • Review your plan's Annual Notice of Change each fall and recheck your medications during AEP (Oct 15–Dec 7)
  • Many people pay hundreds more per year than necessary simply because they didn't review their plan last fall
The PharmSurance difference
Why pharmacy training matters here
What most advisors miss

Your advisor will check formulary tiers, utilization restrictions, and coverage details for every medication you take. But the PharmSurance difference goes further — pharmacy training means your advisor also spots things like upcoming generic availability for brand-name drugs you're currently taking, therapeutic alternatives that might be covered at a lower tier, or utilization restrictions that could delay access. Knowing what to look for changes the quality of the recommendation entirely.

Want us to check your medications?

A PharmSurance advisor will compare your specific drug list against the plan formularies we offer — and show you which one covers your medications at the lowest total cost among them. At no cost to you.

PharmSurance.com

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY 1-877-486-2048) to get information on all of your options. If you submit your information on this site, it will be provided to one or more licensed insurance agents, who may call, email, or text you about Medicare Advantage, Medicare Supplement, and Prescription Drug Plan options. This is a general educational overview only, not specific to any plan.

For consumer use · Not affiliated with the U.S. government or federal Medicare program.

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