Types of UnitedHealthcare Plans
Medicare Prescription Drug (Part D) Plans
What do Medicare prescription drug plans cover?
All Medicare Prescription Drug plans cover the types of drugs most often prescribed for people enrolled in Medicare. This is decided by the U.S. government. But it's up to each plan which specific brand name and generic drugs they will cover within those types. You can find this information by viewing a plan's drug list.
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Medicare prescription drug (Part D) plans cover the types of drugs most often prescribed for people enrolled in Medicare. This is decided by the federal government. Every Part D plan has specific brand name and generic drugs it covers within those types.
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What should I know about a plan’s drug list?
A drug list—sometimes called a formulary—is a list of drugs covered by a plan.
A drug list can change from year to year.
Part D plans may add or remove drugs from their drug list each year. Changes may also be made during the year, for example if a drug is taken off the market. Your plan will let you know if a change affects a drug you are taking.Many Part D plans have a tiered drug list where drugs are divided into groups based on cost.
In general, drugs on low tiers cost you less than drugs on high tiers. Plans may charge a deductible for certain drug tiers and not for others, or the deductible amount may be different depending on the tier.
A drug list (also called a formulary) tells you what drugs covered by a plan.
A drug list can change from year to year.
Part D plans can add or remove drugs from their drug list each year. The list can also change for other reasons. For example, if a drug is taken off the market. Your plan will let you know if there's a coverage change to a drug you're taking.Many Part D plans have a tiered drug list.
Tiers divide drugs into groups based on cost. In general, drugs in low tiers cost you less than drugs in high tiers. Sometimes plans charge deductibles for certain drug tiers.
Drug list tiers:
| Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
|---|---|---|---|---|
|
$ (Lowest cost)
|
$$
|
$$$
|
$$$$
|
$$$$$ (Highest cost)
|
| Tier 1 |
$ (Lowest cost)
|
|---|---|
| Tier 2 |
$$
|
| Tier 3 |
$$$
|
| Tier 4 |
$$$$
|
| Tier 5 |
$$$$$ (Highest cost)
|
What does it mean if my prescription drug has a requirement or limitation?
There are rules for some prescription drugs that limit how and when a plan will cover them. These are called requirements or limitations. If you don't follow these rules or don't get permission from the plan saying you don't have to (called an exception), you may have to pay the full cost of the drug out of your own pocket. You can find out if a drug has any requirements or limitations by looking for the following abbreviations next to the drug names in a plan's drug list:
There are rules for some prescription drugs that limit how and when a plan will cover them. These are called requirements or limitations. If you don't follow these rules or don't get permission from the plan saying you don't have to (called an exception), you may have to pay the full cost of the drug out of your own pocket. You can find out if a drug has any requirements or limitations by looking for the following abbreviations next to the drug names in a plan's drug list:
| PA – Prior Authorization |
The plan needs you or your doctor to get prior authorization before they will agree to pay for this drug. This means the plan needs more information from your doctor about how the drug is going to be used. |
|---|---|
| QL – Quantity Limits |
The plan will cover only a certain amount of this drug or type of drug for one copay or over a certain number of days. For example, the plan may only let you have 30 pills per month of a certain drug. |
| ST – Step Therapy |
There may be lower-cost drugs that work just as well for a medical condition such as this one. The plan might want you to try one or more of these other drugs before it will cover the drug that costs more. |
| B/D – Medicare Part B or Medicare Part D Coverage Determination |
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor might need to give the plan more information about how this drug will be used to make sure it’s being covered by the right part of Medicare. |
Plans have rules that limit how and when they cover certain drugs. These rules are called requirements or limitations. You need to follow the rules to avoid paying the full cost of the drug out-of-pocket. If needed, you and your doctor can also ask the plan for an exception.
Here are the requirements and limitations you may see on a drug list:
| PA – Prior Authorization |
The plan needs more information from your doctor about how the drug is going to be used before it will pay. |
|---|---|
| QL – Quantity Limits |
The plan will cover only a certain amount of a drug or type of drug for one copay or over a certain number of days. |
| ST – Step Therapy |
The plan wants you to try one or more lower-cost alternative drugs before it will cover the drug that costs more. |
| B/D – Medicare Part B or Medicare Part D Coverage Determination |
Some drugs can be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). The plan needs more information about how a drug will be used to make sure it’s covered by the right part of Medicare. |
How can I get the best value from my Medicare prescription drug plan?
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Here are some suggestions to help you make sure your Medicare Prescription Drug plan is a good fit for your health care and budget needs.
- Know the drug list:
Make sure the medication you take is on a plan's drug list. If it's not, check with your provider to see if there's one on the drug list you can switch to.
- Ask if your plan participates in the Part D Senior Savings Model for Insulin1.
- Consider generics:
Ask your provider about generic or low‑cost options for drugs in high tiers or that are expensive.
- Show your member ID card:
Be sure you show your member ID card when you fill prescriptions. That way, you'll be sure to get any cost savings available to plan members.
- Use the mail order pharmacy:
You may be able to save money when you get at least a 3-month supply of your medication delivered to your home.
- Use a preferred network pharmacy:
Many plans offer cost savings if you fill your prescriptions at a pharmacy that's part of the plan's preferred network.
1You will pay a maximum of $35 for a 1-month supply of insulin during the deductible, initial coverage and coverage gap or "donut hole" stages of your benefit. You will pay a maximum of $35 for a 1-month supply of insulin during the deductible, initial coverage and coverage gap or "donut hole" stages of your benefit. You will pay 5% of the cost of your insulin in the catastrophic coverage stage. Your costs may be less if you receive Extra Help from Medicare.
- Know the drug list.
Make sure your medication is on a plan’s drug list. If it’s not, check with your provider to see if there’s one on the drug list you can switch to.
- Consider generics.
Ask your provider about generic or low‑cost options to replace higher-tier or more expensive drugs.
- Ask if your plan participates in the Part D Senior Savings Model for Insulin1.
- Show your member ID card.
Be sure to show your member ID card when filling prescriptions to get any member cost savings.
- Use the mail order pharmacy.
Convenient home delivery of your regular, maintenance medications can save time and money.
- Use a preferred network pharmacy.
Many plans offer cost savings if you fill your prescriptions at a pharmacy that's part of the plan's preferred network.
1You will pay a maximum of $35 for a 1-month supply of insulin during the deductible, initial coverage and coverage gap or "donut hole" stages of your benefit. You will pay a maximum of $35 for a 1-month supply of insulin during the deductible, initial coverage and coverage gap or "donut hole" stages of your benefit. You will pay 5% of the cost of your insulin in the catastrophic coverage stage. Your costs may be less if you receive Extra Help from Medicare.
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Call UnitedHealthcare: 1-855-264-3796 (TTY 711)
Hours: 7 a.m. – 11 p.m. ET, Monday – Friday, 9 a.m. – 5 p.m. ET, Saturda
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Insured by UnitedHealthcare Insurance Company, Horsham, PA (UnitedHealthcare Insurance Company of New York, Islandia, NY for New York residents). Policy form No. GRP 79171 GPS-1 (G-36000-4).
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