I'm confused about the different tiers in Medicare Part D plans. How do they affect what I pay for my medications?
Answered by 18 licensed agents
Answered by Anthony Castelluccio on April 4, 2025
Agent Licensed in PA, DE, MD, NJ & VA
Answered by Larry Dalton on April 3, 2025
Broker Licensed in OK & TX
Answered by Mitch Anderson on June 10, 2025
Agent Licensed in MN, IA & WI
The bottom shelf (Tier 1) has the cheapest stuff — mostly common generics, and they usually cost just a few dollars.
The next shelf up (Tier 2) still has generics, but maybe not the preferred ones, so they’re a little more.
Tier 3 and 4 are where you find brand-name drugs — the ones you see on TV. These cost more.
And Tier 5? That’s the top shelf — the really expensive medications for serious conditions, like cancer or autoimmune diseases. Those are the priciest of all.
So the higher the tier, the higher your cost.
That’s why I always check which “shelf” your medications are on before recommending a plan — so we know your drugs on the formulary and what the estimated costs will be. Remember that these are estimates...no agent will be able to dial in exact costs. The tools are not precise enough to offer this as much as I would like to.
Answered by Yasmine Lopez on June 6, 2025
Broker Licensed in UT, AL, AZ & 17 other states
The Tiers are generally numbered 1-5. The lower the number equals a lower price
Tier 1 – Preferred generics (lowest cost): These are the common meds a lot of us take. Often $0
Tier 2 – Generic drugs: These are less common, but still relatively inexpensive
Tier 3 – Preferred brand-name drugs: Start getting expensive. If you see it advertised on TV, it's a Tier 3 or higher
Tier 4 – Non-preferred drugs: Expensive but often have a lower cost alternative
Tier 5 – Specialty drugs (very high cost) You know if you take one of these
Keep in mind that different carriers may place the same medication in different tiers. Although most are in the same category, it is not a requirement. Make sure you check your medication costs each year.
Answered by Mark Bilgere on July 17, 2025
Broker Licensed in TX, AR, IN & LA, MN, NE & OK
Answered by Nolan Popel on July 8, 2025
Agent Licensed in NY, AZ, CA & 15 other states
I.E most prescribed medications are are rated @ tier 1 or 2, whereas a medication like Eliquis is rated @ tier 3 level which is more expensive with a maximum annual out of pocket expense.
Answered by David Moscowitz on July 7, 2025
Agent Licensed in NY
Tiers are determined by Medicare (CMS) and are based upon the costs of bringing the drug to market (research & development, plus the ingredients). There are some categories of drugs that don't fit into that rule like Insulin ($35.00 apiece) and the ever-escalating costs of various inhalers.
My tip on paying the least amount of money is to always check with the online discount websites like GoodRx.com, costplusdrugs.com, simplecare.com, etc. There are also a number of Canadian online discount pharmacies that are available in order to check their cost to you. Please remember that should you decide to use a Canadian pharmacy, the drug cost will NOT be applied toward the 2025 annual drug deductible (max: $2,000.00).
Be advised that in 2025, you have 2 options: A) Using your Part D(rug) plan or in checking the drug formulary within your Advantage plan, vs. B) using an online pharmacy which you've investigated and contains a less expensive amount by printing a coupon from your PC. BUT, you cannot use both for the same drug. You CAN use either A or B for the various drugs you take, some of which might point you to your favorite local drug store, while others might dictate that you drive further away from your home to a "different" pharmacy which has better pricing for your drug. The only inconvenience is that you must check that your doctor knows which pharmacy to fax to with each individual drug/Rx.
Answered by Steven Bleicher on April 19, 2025
Broker Licensed in AZ
Listed are the tiers found in most plans:
Tier 1-Preferred Generic: Lisinopril, Atorvastatin and Metformin are a few example. $0 copay for these prescriptions
Tier 2-Generic: Little to No Copay
Tier 3-Preferred Brand: A deductible may be required in addition to a higher copay. Eliquis, Ozempic and Trulicity are few examples.
Tier 4-Non Preferred Brand: Same rules apply as Tier 3 but with a higher copay.
Tier 5-Specialty Drugs-Usually has a percentage instead of a copay because of the high cost.
Answered by Timothy Brown on June 7, 2025
Broker Licensed in PA, CT, DE & 15 other states
Newer drugs, biologics and some drugs popular due to their use and success rate will generally be priced in tiers three or tier 4 and have co-pays ranging from $40 to several hundred dollars. You may be able to get a tier exception from the drug plan working with your doctor that can drop a co-pay several hundred dollars.
Answered by Jim Willis on May 5, 2025
Broker Licensed in AZ, CA, CO & 12 other states
Example:
TIER 1: Preferred Generic
TIER 2: Other Generic
TEAR 3: Preferred brand
TEAR 4: Brand
Special: Special
If you already have a Part D plan, we recommend you check with your insurance company or agent to find out what tier the drug you are taking is.
Answered by Satoshi Aoki on April 21, 2025
Agent Licensed in CA
Tier 3 are Brand Name
Tier 4 are specialty drugs
Each tier has a copay associated with it. Tiers 3 and 4 will trigger the annual deductible to be satisfied. Ask your representative for a breakdown of your Drug Plan.
Answered by Tammie Rutledge on April 9, 2025
Broker Licensed in WA, AZ, FL & ID, MT, OR & TX
Answered by Fred Manas on April 21, 2025
Agent Licensed in NY, CT, DC & 7 other states
Answered by Steve Brauer on April 21, 2025
Broker Licensed in AZ & CA
Then just look up the Tier # on your Benefit Summary, & it will tell you the copay $ amount, or the Co-insurance % amount that you will pay for that Prescription!
Answered by Ross Landon on April 29, 2025
Agent Licensed in UT
Tier 1 includes the lowest-cost generic drugs, while Tier 5 covers high-cost specialty medications. Monthly premiums and drug deductibles vary by plan, with some offering no monthly premiums.
If you would like additional information, or have further questions, please feel free to email us at [email protected].
Answered by Betty McCarty on April 10, 2025
Agent Licensed in WA
Tier 1 and 2 are typically not subject to the annual part D drug deductible of $590 in 2025. Part D medication costs are capped at $2000 for the calendar year including the $590 deductible and all co-pays and co-insurance. This is new for 2025 under the Inflation Reduction Act passed in 2022.
Answered by Donald Heath on May 12, 2025
Agent Licensed in CA, AZ, CO & NM, NV, TX & WA
There are 5 Tiers for Prescriptions within Medicare Plans. Starting with Tier 1 being the least expensive.
Each Carrier has a different formulary for how they classify a prescription in what Tier and how much your monthly copay would be for that prescription. Additionally if the drug is classified as a Tier 3 - Tier 5 it may also have an annual deductable amount assoicated with it.
If you are required to pay an annual deductible you only pay it once a year regardless of how many T3 - T5 scripts you are on.
Therefore, prescription drug costs vary by Carrier and plans. It is very important to provide all of you prescription drug information to a representative so they can research your best options. Or you can research this information yourself through the CMS website.
Typically the costs in NY for 2025 are something like this:
Tier 1 - Preferred Generic (often no $0 monthly copay)
Tier 2 - Generic (range from $10 to $20 monthly copay)
Tier 3 - Preferred Brand Name Drugs (range from $42 - $47 monthly copay) and an annual deductible may apply
Tier 4 - Non-Preferred Drugs (your copay maybe a flat $ for a % of the drug cost (coinsurance) and an annual deductibe may aply
Tier 5 - Specialty Drugs (your copay will most likely be a % of the drug cost) and an annual deductible may apply.
Keep in mind most of the carriers have direct mail order services which typically offer you the ability to pay two months of copayments for a 90-day supply.
I hope this helps clarify your confusion.
Answered by Kathleen Emert on June 30, 2025
Broker Licensed in NY, FL & PA
Tags: Medicare Part D Prescription Drug
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