Text size+-
medicare RX

Using The Formulary

All Medicare Part D plans use a formulary -- a list of drugs covered by the Part D plan you selected. You should check the formulary for your Part D plan before getting a prescription filled to make sure the drug is covered by the plan.

Click the titles below to learn more about the formulary and how it affects your drug coverage.

  • Check The Formulary Before You Fill a Prescription

    All Medicare Part D plans use a formulary -- a list of drugs covered by the Part D plan you selected. You should check the formulary for your Part D plan before getting a prescription filled to make sure the drug is covered by the plan.

    You can get up to a 90-day supply for most covered drugs, but specialty drugs are limited to a 30-day supply.

    Some drugs require prior authorization or step therapy, and some drugs have quantity limits. You can review the Plan's criteria for requiring prior authorizations for certain drugs.

    The formulary may change throughout the year. Each formulary is reviewed and updated on a regular basis by medical and pharmacy professionals. Changes to the formulary are listed on your Explanation of Benefits (EOB) at least 60 days in advance. Or, you can review the Notice of Formulary Updates.

    To find out if a specific drug is covered, you can

    NRECA has two formularies for its Part D plans:

    Please read the introduction to the formulary. It explains

    • how to use the formulary
    • what drugs are excluded by Medicare
    • what to do if your drug requires prior authorization or step therapy, may be covered by Part B or Part D, or has quantity limits
    • what to do if the formulary changes
    • what to do if a drug you are taking is no longer on the formulary
    • what to do if you disagree with a drug coverage or payment decision

    Remember to use a network retail pharmacy or the mail order pharmacy to be covered by the plan, except in an emergency or non-routine circumstance.

    If you have any questions, call Customer Care.

  • If Your Drug Is Not On the Formulary

    You may be taking a drug that is not covered on the formulary (list of drugs) for your new Part D plan when

    • You enroll in a Part D plan for the first time
    • You change to a different Part D plan
    • You move into or out of a long-term care facility

    If so, you may be able to receive a limited supply of this non-formulary drug to help you transition to the drugs available on the new Part D plan. For 2014, this transition coverage is available if you

    • switched from one plan to another after January 1, 2014
    • enrolled in a new plan during open enrollment held October 15 - December 7, 2013 and your coverage is effective January 1, 2014
    • are newly-eligible for Medicare during 2014 and were covered by another plan immediately before enrolling in a Part D plan
    • move into or out of a long-term care facility during 2014

    How Transition Coverage Works

    During the first 90 days you are enrolled in the Part D plan, you may receive up to a 30-day transition supply of a non-formulary drug. This will give you time to talk to your doctor about other medications you may take that are included in the formulary for your plan.

    If you are in a long-term health care facility

    • during the first 90 days that you are enrolled in the plan, you may receive a transition supply of up to 14 days and  the plan may cover refills until the end of the 90-day transition period.
    • after 90 days, you may receive a transition supply of up to 14 days

    This transition supply is only available for

    • non-formulary drugs covered by Medicare
    • formulary drugs that are subject to prior authorization, quantity limits or step therapy that were not required by your previous plan

    For the Copayment Plan only, you will pay for this transition supply

    • the non-preferred brand name (Tier 3) copayment for non-formulary drugs
    • the tier listed in the formulary for drugs subject to prior authorization, quantity limits or step therapy

    If Your Drug is No Longer on the Formulary

    If you find out that your drug will no longer be on the formulary, you should talk with your doctor who prescribed the non-formulary drug about

    • changing from a non-formulary drug to an alternative drug that is included on the formulary
    • getting any prior authorizations that may be required for certain medications
    • requesting a coverage decision or formulary exception for a non-covered drug by completing and submitting a coverage decision form

    You may receive up to a 30-day transition supply of a drug that was removed from the formulary. This will give you time to talk to your doctor about an alternative drug.

    It is your responsibility to check the formulary before going to the pharmacy to get your prescription filled. To find out if your drug is covered

    You should check and make sure that

    • your medications are covered by your Part D plan
    • you are aware of any prior authorizations or step therapy that may be required
    • you are aware of any quantity limits.

    If you have any questions, please contact Customer Care.

  • Drugs And Drug Categories Not Covered By Medicare

    Medicare will not cover certain drugs under Part D. The excluded drugs and drug classes are:

    • drugs used for weight loss, weight gain or anorexia
    • drugs used for infertility
    • drugs used for cosmetic purposes or hair growth
    • drugs used for relief of coughs or colds
    • drugs for erectile dysfunction, such as Viagra, Levitra or Cialis, unless used to treat other approved conditions
    • prescription vitamins and mineral products except prenatal vitamins and fluoride preparations
    • non-prescription drugs available over-the-counter
    • compounded drugs, unless the major component is a Part D drug.

    You can continue to get a Medicare-excluded drug at a retail pharmacy, but it is not covered by your Part D plan. You will have to pay the entire cost for the drug, and the cost will not be applied to your deductible or your true out-of-pocket (TrOOP) total.

    The coverage decision and appeals processes do not apply to these drugs. Also, these drugs are not covered for a transitional or emergency fill through your Part D plan.

  • Notice of Formulary Updates

    NRECA may add or remove drugs from our formulary during the year.

    Changes to the formulary are listed on your Explanation of Benefits (EOB) at least 60 days in advance. These changes may include

    • a drug removed from the formulary
    • requirements such as prior authorization, quantity limits, or step therapy added for a drug

    A drug will be removed immediately from our formulary without notice if

    • the Food and Drug Administration deems a drug on the formulary to be unsafe
    • the drug's manufacturer removes the drug from the market

    Choose an option below to see the changes to the formulary for your plan:

    • There are no changes at this time. 


  • Types Of Drugs

    Generic drugs: Prescription drugs that have the same active ingredient as brand-name drugs, are required by the Food and Drug Administration (FDA) to be as safe and effective as the brand-name drug, and usually cost less than brand-name drugs. These drugs appear in lower case italics in your formulary.

    Brand-name drugs: Prescription drugs that are protected by patent and typically produced and sold by one manufacturer. These drugs appear in ALL CAPITAL LETTERS in your formulary. 

    • Preferred brand: Brand-name drugs that are included on a preferred drug list and are usually available at a lower cost than non-preferred brand-name drugs.
    • Non-preferred brand: Brand-name drugs that are not on the preferred drug list but are still included in the Part D Plan formulary.
    • Specialty drugs: High-cost biotech and other unique drugs used to treat specific conditions. Limited to a 30-day supply each time you get your prescription filled.
  • Medication Therapy Management Program (MTMP)

    We offer a program that can help plan members know more about their medications. Some members have several complex medical conditions. Others may need to take many drugs at the same time, or they may have very high drug costs. This program helps members manage their drugs and helps reduce potential problems. The Medication Therapy Management Program can help you and your doctors get the most benefit from your drugs.

    If you qualify, this program is offered at no additional cost.

    MTMP Personal Medication List - English
    MTMP Personal Medication List - Spanish

    Who qualifies for MTMP?

    You will be automatically enrolled in this program if you:

    • Take eight or more Medicare Part D covered maintenance drugs and
    • Have three or more long-term health conditions, such as diabetes, asthma or high blood pressure and
    • Spend more than $3,017 a year on your drugs

    How will I know if I qualify?

    You will receive an invitation to have a personal phone call with one of CVS Caremark's pharmacists once you qualify. The pharmacist will review all of the drugs, vitamins and herbal products you are taking and discuss them with you. Please note that not all plan members will qualify for the Medication Therapy Management Program, therefore the program is not considered a benefit.

    How does it work?

    This program works with you and your doctor to help make sure the drugs you are taking are safe and effective for you. Specially trained pharmacists will review your drugs. Your doctor may be contacted directly if there is a question about your drugs. When you talk to the pharmacist, he or she can let you know ways to better manage your conditions with your drug therapy. You will be invited to review all of your drugs and any other vitamins or herbal products you take with one of our pharmacists. The pharmacist will be able to answer any questions and address any concerns you have.

    What if I don’t want to participate in MTMP?
    If you would like more information about this program or you do not want to take part in the MTMP, please call Customer Care.

get adobe now

You may need to download and install the Adobe Reader to view some documents (PDFs) on this site.
Click on the button to download the free software from Adobe Systems.

Copyright © NRECA
NRECA is a Medicare-approved Part D Plan sponsor.
This site last updated 9/2014  |  E2332

Domain names, trademarks and copyrights of other websites or of, or contained in, information on this website are the sole property of their respective owners.

Site Developed By: MindStreams