How to Check if Your Drugs are Covered
In most cases, a plan does not pay benefits for any drug not listed on the formulary, which is a list of all the medications covered by a plan. The formulary can also indicate if a prior authorization or step therapy is required for certain drugs as well as any quantity or day supply limitations.
If you are enrolled in one of the Medicare Rx Options under the Health Options Program, the comprehensive formulary for each Option is posted to the website and updated monthly.
There are two ways to look up your medications in the formulary:
- Medical Condition. The drugs are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what your drug is used for, look for the category name. Then look under the category name for your drug.
- Alphabetical Listing. If you are not sure what category to look under, you should look for your drug in the Index. The Index provides an alphabetical list of all of the drugs included in the formulary. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
You can also use the online Part D Formulary Lookup Tool to see if a medication is covered. To search for drug pricing information, you must be registered on the OptumRx website. OptumRx is the administrator for the Medicare Rx Options under the Health Options Program.
As a reminder, the 2020 Materials page has links to the electronic files of all the materials that were mailed to current members. Click on a link to view, print or download a copy of each document.
If you are enrolled in a Medicare Advantage Plan, ask the insurance provide for their formulary.