The different Medicare tiers, in order from first to fifth, are preferred generic, generic, preferred brand, nonpreferred brand and specialty, states Blue Cross Blue Shield of Michigan. The first tier covers the most frequently used generic drugs, while the second tier covers remaining generic drugs. The third tier includes the most affordable brand drugs, and the fourth includes more expensive brand drugs that may be equivalent to a generic drug. The fifth tier covers drugs for highly complex conditions.
Each plan makes its own decisions regarding assigning drugs to tiers, explains Medicare.gov. Each drug’s cost depends on what tier it is in and, as a rule, higher tiers have higher prices. In some cases, patients may be able to get a particular drug for a lower price if their prescribing physician thinks they need that drug instead of one from a lower tier. A plan may alter its list of drugs during a given year, but only within parameters set by Medicare.
All Medicare Prescription Drug Plans typically have quantity limits, step therapy and prior authorization, as noted by Medicare.gov. Quantity limits restrict the amount of medication available to the patient during any period. Step therapy requires patients to use at least one cheaper drug with a similar effect before prescribing a higher-priced drug. Prior authorization requires that the patient or the prescribing physician contact the plan and confirm medical need before the drug is prescribed. The patient or his prescribing physician may ask for a waiver of any of these rules.