How Do You Check Your Drug Coverage for Next Year?

Look up each of your current prescriptions in the plan's next-year formulary, note the tier assigned to each drug and any restrictions like prior authorization or step therapy, and confirm that your preferred pharmacy remains in the plan's pharmacy network. Affordable Medicare Quote helps licensed agents deliver exclusive leads from beneficiaries reviewing these details during AEP.

Where do you find a plan's formulary?

Most Medicare Advantage and Part D carriers publish their formularies on their member portal or a public PDF library, typically searchable by drug name or NDC. CMS requires plans to post these by late September for the following plan year.

You can also call the plan's customer service number printed on the ID card and request a copy by mail, though the online tool is faster. The formulary lists every covered drug, grouped by tier, and flags any quantity limits, refill schedules, or step-therapy requirements. Many plans also embed the lookup inside their Medicare.gov profile, accessible through the Medicare Plan Finder.

What do drug tiers mean?

Prescription tiers group drugs by cost-share: Tier 1 usually covers generics with the lowest copay, Tier 2 preferred brands, Tier 3 non-preferred brands, Tier 4 specialty drugs, and sometimes a Tier 5 for high-cost biologics. Your out-of-pocket amount climbs as the tier number rises.

A drug you take today may move to a higher tier next year, raising your copay or triggering coinsurance instead of a flat copay. Some plans offer low Tier 1 copays and push Tier 4 to percentage-based coinsurance. Review every medication's tier assignment in the new formulary and compare it to your current plan's structure. If a key drug jumps two tiers, that shift can add significant cost per month.

Item to check	Where to look	Why it matters
Drug tier	Plan formulary (online or PDF)	Higher tier = higher copay or coinsurance
Restrictions	Formulary notes column	PA, step therapy, or quantity limits delay fills
Pharmacy network	Plan pharmacy directory	Out-of-network = full retail price
Preferred vs standard	Pharmacy tier list	Preferred pharmacies offer lower copays

What are coverage restrictions?

Coverage restrictions include prior authorization (the plan must approve the drug before filling), step therapy (you must try a cheaper alternative first), and quantity limits (a maximum number of pills per fill). Each restriction appears next to the drug name in the formulary.

Common restrictions:

• Prior authorization – Your doctor submits clinical justification; approval time varies by plan.
• Step therapy – You start with Drug A; if it fails, the plan covers Drug B.
• Quantity limits – Limits the number of tablets per fill, blocking stockpiling or early refills.

If a drug you rely on gains a new restriction, confirm with your prescriber whether they can document medical necessity or switch you to an unrestricted alternative before January 1.

How do you verify your pharmacy is still in network?

Check the plan's online pharmacy directory or call the plan to confirm your current drugstore appears in next year's network and that it remains a preferred (Tier 1) pharmacy if cost matters. Pharmacy networks can shrink or shift preferred status each plan year.

Using an out-of-network pharmacy may leave you paying full retail price, and even in-network pharmacies split into "preferred" and "standard" tiers with different copays. Mail-order pharmacies often sit in the preferred tier for 90-day fills, offering lower per-unit costs. If your neighborhood pharmacy drops out, ask the plan for the nearest alternative or request a network exception if the closest in-network option is more than a reasonable distance.

How Affordable Medicare Quote handles this

Affordable Medicare Quote delivers exclusive Medicare leads—live transfers, call backs, aged inventory, and raw data—to licensed agents nationwide, including beneficiaries actively reviewing drug coverage during AEP. Because the inventory is exclusive, you reach prospects before competitors do, and many callers are comparing formularies and pharmacy networks right when they contact you.

Leads are filtered by your licensed states, and you can request volume scaled to your floor capacity. Agents request a custom inventory quote by phone or through the contact form.

Frequently asked questions

When are next-year formularies available?

Most carriers publish them by late September, giving beneficiaries time to review before AEP opens October 15. Some plans release updates as early as mid-September.

Can a plan drop a drug mid-year?

CMS allows mid-year removals only if the FDA deems the drug unsafe or a generic equivalent becomes available. Otherwise, the formulary is locked until the next January 1.

What if my drug isn't on the new formulary at all?

Ask your doctor to request a formulary exception, or switch plans during AEP. If the exception is denied, you have until December 7 to enroll in a different plan that covers it.

Do I need to check every prescription?

Yes. Even if most drugs stay the same, one tier change or new prior authorization can significantly raise your costs. Review each drug individually.

How often do pharmacy networks change?

Networks can change every plan year. A pharmacy in-network today may be dropped or downgraded to standard tier, increasing your copay.

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