Understanding the Tier System for Medications—Four Questions Answered

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Understanding the Tier System for Medications—Four Questions Answered

 
Get to know your Medicare Part D prescription drug plan or Medicare Advantage plan’s tier system for medicationsMedicare Part D (prescription drug plans) and Medicare Advantage (Part C) divide types of medications into groups called “tiers” in order to determine costs. Each of the tiers has a different copay, coinsurance and cost-sharing for the beneficiary. Here are answers to four common questions about the tier system:

1. Are tiers the same for all plans? No. Each plan, and there are many providers for Medicare plans, decides its own tier system. Most plans have between three and five tiers.

2. How do the tiers work? The lower the tier number, the lower your out-of-pocket costs; the higher the tier number, the more expensive. Here is how it works in 2011:

  • Tier 1 is usually the generic prescription drugs.
  • The next tier is usually the “preferred” brand-name medications, or, in other words, the drugs that your insurance provider has negotiated with select pharmaceutical companies to get for a better rate.
  • The next tier is usually the “non-preferred” brands, or drugs that treat the same things as the “preferred” brands, but from other companies.
  • The drugs on the highest tier are often unique, specialty drugs. They cost the most.

3. How do I learn what costs to expect? Get to know your plan’s tiers. This information is often available on your plan provider’s website, or you may call them to ask. Knowing which tier your medications are on beforehand lets you know how much your copy or coinsurance will be.

4. How can I lower my copay? Sometimes your doctor may suggest a more expensive drug on a higher tier, but you may still be able to get a similar drug on a lower tier. Discuss with your doctor whether or not lower cost drugs may work for you. If not, you may file an exception and ask your plan to allow you to pay the lower copayment for the higher-tier drug.

Being informed about your plan’s tier system is vital to taking charge of your medication costs and taking charge of your health.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. You can also contact UnitedHealthcare® Medicare Made Clear to learn more at 1-877-619-5582, TTY 711, 8 a.m. - 8 p.m. local time, seven days a week.

Resources:

 Y0066_110719_105903 File & Use 07252011