How to Check Drug Coverage Tiers and Formulary Changes for Medicare Part D

How to Check Drug Coverage Tiers and Formulary Changes for Medicare Part D Dec, 28 2025

Every year, thousands of seniors face surprise increases in their medication costs-not because prices went up, but because their insurance plan quietly moved their drug to a higher tier. If you're on Medicare Part D or a private plan with a formulary, you need to know how to check your drug coverage before filling each prescription. This isn't optional. It's the difference between paying $10 or $60 for the same pill.

What Is a Drug Formulary and Why Does It Matter?

A drug formulary is simply the list of medications your insurance plan covers. But it’s not just a list. It’s broken into tiers, and each tier determines how much you pay out of pocket. Tier 1 usually means the lowest cost. Tier 5? That’s where specialty drugs like weight loss injections or cancer treatments land-and those can cost hundreds per month.

Medicare Part D plans have to cover at least two drugs in every therapeutic category. That sounds fair, right? But here’s the catch: the same drug can be in Tier 1 with one plan and Tier 3 with another. For example, metformin, a common diabetes drug, might cost $5 with one insurer but $20 with another, depending on where it’s placed. That’s why checking your formulary isn’t a one-time task. It’s an annual habit.

How Formulary Tiers Work (And How They Change)

Most plans use either a 3-tier, 4-tier, or 5-tier system. Here’s what you’ll typically see:

  • Tier 1: Preferred generics. These are the cheapest. Think $5-$10 per prescription.
  • Tier 2: Non-preferred generics or lower-cost brand-name drugs. Usually $15-$30.
  • Tier 3: Higher-cost brand-name drugs with generic alternatives available. Often $40-$70.
  • Tier 4: Non-preferred brand-name drugs with no cheap alternative. Can be $80 or more.
  • Tier 5: Specialty drugs. These include GLP-1 medications like Wegovy or Ozempic, injectables, and complex treatments. Costs range from $100 to $1,000+ per month.
Changes happen all the time. When a new generic hits the market, insurers often move the brand-name version up a tier to push people toward the cheaper option. That’s legal-and common. In 2023, about 17% of formulary changes involved moving drugs to higher tiers, according to Avalere Health. That means if your blood pressure pill was in Tier 1 last year, it might be in Tier 3 this year. And you won’t know unless you check.

How to Check Your Drug’s Tier (Step by Step)

You don’t need to be a tech expert. Here’s how to do it in under 10 minutes:

  1. Find your plan’s formulary tool. Go to your insurance provider’s website. Look for “Drug List,” “Formulary,” or “Find a Drug.” Most plans, like Cigna, Humana, or Excellus BCBS, have a search bar right on the homepage.
  2. Enter your exact drug name. Use the brand name if you’re unsure. For example, type “Lisinopril” instead of “high blood pressure pill.”
  3. Check the tier and cost. The tool will show you the tier (1-5) and your copay or coinsurance. Look for “preferred” or “non-preferred” labels-those matter.
  4. Compare alternatives. If your drug is in a high tier, the tool will often suggest lower-cost alternatives in the same class. Ask your pharmacist: “Is there another drug like this that’s cheaper on my plan?”
  5. Save the page. Take a screenshot or print it. You’ll need it if you need to file an exception later.
Pro tip: Don’t wait until you’re at the pharmacy. Do this before your prescription renews. Most formularies update on January 1st, but changes can happen anytime.

An elderly person stands on a floating tablet, using a discount card to block rising drug prices with a glowing shield.

When Your Drug Gets Moved to a Higher Tier

If your drug suddenly costs more, you’re not alone. In Q3 2023, 42% of customer service calls to Simply Prescriptions were about unexpected tier changes. But you have rights.

First, check your mail. By law, your plan must send you a written notice if they’re changing your drug’s tier or removing it entirely. The notice must say when the change takes effect and tell you how to request an exception.

Next, talk to your doctor. You can ask them to file a formulary exception request. This is a formal request asking your plan to cover your drug at a lower tier because:

  • The alternative drugs didn’t work for you
  • You have side effects from other drugs in the same class
  • Your condition requires this specific medication
In 2022, about 1.2 million exception requests were filed. Approval rates ranged from 55% to 82%, depending on your plan and how strong your medical justification was. One Medicare member in Melbourne shared: “My doctor wrote a letter explaining why I couldn’t switch from my current statin. My plan approved it-and kept my cost at $10.”

What to Do If You Can’t Get an Exception

Sometimes, your request gets denied. That’s frustrating-but not the end. Here’s what to try next:

  • Ask your pharmacist for a 30-day supply. Many plans offer a transition supply if your drug was previously covered. This gives you time to switch or appeal.
  • Use GoodRx or SingleCare. These discount cards often beat your plan’s copay, even on Tier 5 drugs. Sometimes, the cash price is lower than your insurance rate.
  • Switch plans during Open Enrollment. If your drug keeps moving up tiers, it might be time to change plans. Use Medicare.gov’s Plan Finder tool to compare formularies side by side.

Red Flags That Your Formulary Is Hard to Navigate

Not all plans make this easy. Watch out for:

  • No online formulary tool (or it’s broken)
  • Formulary PDFs that are 50 pages long with tiny print
  • Customer service can’t tell you your drug’s tier without your member ID and date of birth
  • No clear explanation of what “preferred” means
In 2023, UnitedHealthcare scored 4.2 out of 5 for formulary clarity. Smaller regional plans? Only 2.8. If your plan feels like a maze, reach out to your State Health Insurance Assistance Program (SHIP). They offer free, local help-no cost, no sales pitch. In 2022, SHIP helped over 1.7 million people understand their drug coverage.

A wise AI robot with an open chest displaying colored prescription drugs, a person pressing an exception button on its palm.

What’s Changing in 2025 and Beyond

The biggest trend? GLP-1 weight loss drugs like Wegovy and Ozempic are being moved into the highest tiers. FepBlue admitted in September 2023 that some 2026 formularies still list these drugs incorrectly. That means even if you’re covered now, your cost could jump next year.

CMS is pushing for simpler, standardized tiers. By 2025, they’re piloting a uniform 4-tier model across Medicare Part D plans. That’s good news. Right now, the lack of standardization is confusing. A 2022 survey found 68% of Medicare beneficiaries didn’t understand their formulary tiers-and that confusion led to skipped doses and hospital visits.

Future plans will use AI to recommend lower-cost alternatives based on your history. By 2025, 78% of insurers plan to roll out these tools. But until then, you’re still the best advocate for your own care.

Final Checklist: Your Annual Formulary Review

Do this every October, before Open Enrollment ends:

  • Write down every drug you take, including over-the-counter ones your doctor recommended
  • Check each one’s tier and cost on your plan’s website
  • Compare your plan’s formulary to other plans using Medicare.gov’s Plan Finder
  • Call your pharmacist and ask: “Is there a cheaper drug that works the same way?”
  • Save your formulary page. Print it or screenshot it. You’ll need it next year.
If you don’t check your formulary, you’re gambling with your health-and your wallet. Don’t wait for a surprise bill. Take five minutes now. It could save you hundreds.

How often do drug formularies change?

Formularies update annually on January 1st, but changes can happen anytime during the year. Plans must notify you in writing if they remove a drug or add new restrictions. For safety reasons, they can change a drug’s tier immediately-but they must still cover your current supply for at least 30 days while you appeal or switch.

Can I get my drug covered if it’s not on the formulary?

Yes. You can request a formulary exception through your plan. Your doctor must submit a letter explaining why you need that specific drug-usually because alternatives didn’t work or caused side effects. Approval rates vary from 55% to 82%, depending on your plan and medical evidence. Don’t assume it’s denied-ask.

Why is my generic drug suddenly more expensive?

If your generic was moved from Tier 1 to Tier 2, it’s likely because the plan added a new, cheaper generic to the market. Insurers often reposition older generics to push patients toward the lowest-cost option. This is legal and common. Check your plan’s formulary tool to see if there’s a newer generic available at a lower cost.

Are brand-name drugs always more expensive than generics?

Not always. Sometimes, a brand-name drug is in a lower tier than a generic because the generic is newer or less preferred by your plan. Always check your specific plan’s formulary. Also, discount cards like GoodRx often offer brand-name drugs at lower prices than your insurance copay.

What should I do if my plan doesn’t have an online formulary tool?

Call your plan’s customer service line. They’re required by Medicare to provide formulary information over the phone. Ask for your drug’s tier and copay. If they can’t answer, ask to speak with a pharmacy benefits manager. If you’re still stuck, contact your local SHIP office-they offer free, personalized help with formularies and exceptions.

Can I switch plans if my drug moves to a higher tier?

Yes-but only during Open Enrollment (October 15 to December 7) or if you qualify for a Special Enrollment Period. If your drug is removed from the formulary entirely, you can switch outside of Open Enrollment. Always compare formularies before switching. A plan that covers your drug well now might drop it next year.

Next Steps: What to Do Right Now

If you’re on Medicare Part D or any prescription drug plan:

  • Go to your plan’s website and search for your top three medications.
  • Write down the tier and copay for each.
  • If any cost more than $20, ask your pharmacist about alternatives.
  • If you’re unsure, call your State Health Insurance Assistance Program (SHIP). They’re free, local, and don’t sell anything.
Don’t wait for your next pharmacy bill. Check today. One quick search could save you hundreds-or even thousands-over the next year.
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13 Comments

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    Janette Martens

    December 30, 2025 AT 01:49
    I tried checking my formulary last year and my insulin went from $12 to $89 overnight. No warning. No mercy. Canada’s system is broken too but at least we don’t get hit with these surprise bills. #MedicareIsARoulette
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    Marie-Pierre Gonzalez

    December 31, 2025 AT 03:54
    Thank you for this comprehensive guide. I have shared it with my elderly mother who is currently navigating her first year on Medicare Part D. Her pharmacist was unaware of the tier changes until she showed him the updated formulary. Your advice to save screenshots is invaluable. I hope more seniors take this seriously.

    With gratitude,
    Marie-Pierre
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    Louis Paré

    December 31, 2025 AT 22:47
    Let’s be real - this whole system is a scam. Insurers don’t care about your health. They care about profit margins. They move drugs to higher tiers not because of clinical evidence, but because they can. And you? You’re just a revenue stream with a prescription. This isn’t healthcare. It’s corporate extortion dressed in white coats.
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    Gran Badshah

    January 1, 2026 AT 07:02
    I live in India and we dont have this tier system. My dad gets all his meds from local pharmacy for $2 a month. Why do Americans pay so much? Is it because of pharma lobbying? Or just because everyone is too lazy to fight back?
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    Ellen-Cathryn Nash

    January 1, 2026 AT 07:13
    I used to think this was just a financial issue. Then my neighbor skipped her heart meds because the copay jumped to $75. She ended up in the ER. That’s not a cost. That’s a moral failure. And yet, here we are - still scrolling past the formulary updates like they’re spam emails. We’re not just passive. We’re complicit.
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    Samantha Hobbs

    January 1, 2026 AT 12:12
    I just checked my formulary and my zoloft moved to tier 3. I’m literally crying. I’m on a fixed income. This isn’t a ‘surprise’ - it’s a trap. And no one tells you until you’re at the counter with your card in hand.
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    Nicole Beasley

    January 3, 2026 AT 06:10
    I just used GoodRx for my Ozempic and saved $400 😱 I didn’t even know it was an option. This whole system is wild. I’m printing this out and taping it to my fridge. 📌💊 #MedicareHack
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    sonam gupta

    January 4, 2026 AT 22:08
    Formulary changes are just another way to punish the old and sick. No one in government cares. They get their bonuses. We get our bills. Simple as that
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    Julius Hader

    January 5, 2026 AT 10:10
    I’ve been helping my aunt with her meds for years. She’s 78. She cries every time she gets a bill. I showed her how to use the Plan Finder. She said, 'Why didn’t we know this sooner?' That’s the real tragedy - it’s not the cost. It’s the silence.
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    Vu L

    January 7, 2026 AT 03:32
    This post is just corporate propaganda dressed up as helpful advice. You think checking your formulary fixes the problem? Nah. It just makes you feel like you’re in control while the system keeps robbing you. The real fix? Single-payer. But you won’t hear that from the insurance ads.
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    James Hilton

    January 8, 2026 AT 10:31
    Americans: You pay more for drugs than any other country. And you still think you’re getting a deal? 🤡 Here’s your free tip: Stop trusting the system. Use GoodRx. Call your SHIP. Print the damn formulary. You’re not a patient. You’re a customer. Act like it.
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    Mimi Bos

    January 8, 2026 AT 20:12
    I checked my formulary and my blood pressure med moved to tier 4. I called my plan and they said 'We sent you a notice.' I never got it. I think they just mail it to the wrong address on purpose. I'm so tired.
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    Payton Daily

    January 10, 2026 AT 00:45
    This is why I don’t trust any system that lets corporations decide who lives and who dies. It’s not healthcare. It’s a game of Russian roulette with pills. The government lets this happen because the lobbyists pay more than the voters. I used to believe in democracy. Now I just pray my meds don’t get moved next year.

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