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Know Your Plan: Questions You Should Ask About Your Plan

Understanding the ins and outs of your plan is important. Here are some questions to get you started in understanding your Medicare pharmacy benefit:

• Does the PDP require that my health care provider and I choose medicines from a formulary, or list of covered medicines? If so, are my prescriptions on the PDP's formulary?
• If I need a medicine that is not on the formulary, what is the process for requesting coverage?
• Does the PDP require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?
• If there is a less expensive medicine than the one my health care provider prescribes for me, will my PDP require me to try the cheaper one first? (This is called step therapy.)
• Will the PDP ever call my health care provider to ask him or her to switch me to a different, cheaper medicine? (This is called therapeutic substitution.)
• How much are my co-payments, or what I owe the pharmacy when I get a prescription?
• What are the different levels or tiers of co-payments? What types of medicines are in each tier, and what is the amount for each? Do my different medicines fall into different tiers?
• Is my pharmacy in the PDP's network?