What does PA next to my drug mean?

PA stands for Prior Authorization — your prescriber must submit a form with clinical justification before the plan pays. Without the PA, the pharmacy claim will be rejected even though the drug is technically on the formulary. Ask your prescriber’s office to submit the PA; they can usually do it same-day for urgent drugs.

Why is my drug Tier 4 instead of Tier 2?

Tiers reflect a combination of the drug’s cost to the plan, whether it’s brand or generic, and whether the plan has negotiated a rebate. You can request a tier exception — your prescriber submits a form arguing medical necessity for the specific drug. If approved, you pay the lower tier’s copay.

My plan removed my drug mid-year — what do I do?

Medicare plans must give 60 days’ notice before removing a drug or raising its tier. You have three options: (1) switch to the preferred alternative, (2) request a formulary exception to keep the drug, (3) use a 60-day transition supply while you decide. Call the plan immediately — don’t wait until you’re at the pharmacy.

Where do I look up my drug on RxCopays?

Search by brand name at rxcopays.com/drugs. The drug page shows copay cards, patient assistance programs, and any Medicare Part D PA rules we’ve indexed. For your specific commercial plan, always cross-reference the formulary on your insurer’s member site — commercial plans vary widely.

How to read your insurance formulary (without losing your mind)

Your plan’s formulary — the list of drugs it covers — is the single document that predicts your copay most accurately. Once you can read it, you’ll know your out-of-pocket cost before you ever hand a prescription to the pharmacist. Here’s a tour.

Where to find it

Every Medicare Part D plan and every commercial plan publishes a formulary (sometimes called a “drug list” or “preferred drug list”). For:

Medicare Part D: look it up at medicare.gov/plan-compare or on your plan’s member portal.
Commercial insurance: log in to your insurer’s member site; search “formulary” or “drug list”. It’s usually a PDF.
Medicaid: each state publishes a Preferred Drug List (PDL) on its Medicaid agency site.

The five things to look for

1. Is the drug covered at all?

If your drug isn’t on the formulary, it’s “non-formulary” — your plan won’t pay for it. You can pay cash, request a formulary exception, or switch to a covered alternative. Don’t assume a common drug is covered; most formularies exclude some widely-used ones.

2. What tier is it?

Covered drugs are assigned to tiers. Standard Medicare Part D has 5 tiers; commercial plans vary (usually 3-5). Lower tier = lower copay:

Tier 1 — preferred generics. Copay often $0-$10.
Tier 2 — generics (or preferred brand). $10-$25.
Tier 3 — preferred brand. $40-$50.
Tier 4 — non-preferred. $80-$100 or 25-40% coinsurance.
Tier 5 / Specialty — specialty drugs (typically $500+/month wholesale). Usually coinsurance (25-33%) rather than flat copay.

The formulary shows each drug’s tier. Cross-reference with your plan’s Summary of Benefits for the actual dollar copay per tier.

3. Are there restrictions?

Watch for these codes next to the drug name:

PA (prior authorization) — your prescriber must submit a PA form before the plan pays.
ST (step therapy) — you must try and fail on a cheaper drug first.
QL (quantity limit) — you can only get X units per month (e.g., 30 tablets).
B/D — Medicare only; drug covered under Part B in some settings, Part D in others.
LA — limited access (dispensed only through specialty pharmacy).

4. What’s the preferred alternative?

If your drug is Tier 4 or non-formulary, the formulary often lists a preferred Tier 2 or 3 alternative. Ask your prescriber whether the alternative is clinically equivalent. For many conditions (statins, SSRIs, PPIs), switching is straightforward and cuts copays dramatically.

5. When does it change?

Formularies change throughout the year with notice — Medicare requires 60 days’ notice for most changes. If your drug gets moved to a higher tier or removed, you’ll get a letter. Don’t ignore it; request an exception or switch immediately.

Medicare Part D has a public lookup we maintain

RxCopays indexes 7,000+ Medicare Part D prior-authorization and tier rules from CMS’s quarterly Standard Public Use File. You can look up any drug at rxcopays.com/prior-authorization to see its tier, PA, and step-therapy status across Part D plans.

The one-page cheat sheet

Find the formulary (plan website or Medicare.gov).
Look up your specific drug — exact brand name matters.
Note the tier number and any PA/ST/QL restrictions.
Match the tier to your Summary of Benefits for the dollar copay.
If Tier 4+ or restricted, ask about a preferred alternative.