Medicare Part D prescription drug plans can change their plan formulary or drug list throughout the plan year - and you may find that new Part D drugs are added - or dropped - or formulary drugs may have new usage management restrictions (such as needing prior authorization (PA) before filling a prescription).
If one of your brand-name medications is dropped during the plan year when a new generic or alternative medication is added to your formulary or in extreme situations such as when the FDA immediately halts the use of a drug for safety reasons -- your Medicare Part D plan can make the change immediately -- without notifying you. However, if your medication is replaced with a medication that has been on the market (not new), your plan must provide you with a 30-day notice of the formulary change or a 30 day refill.
Related Topic: Asking your Medicare Part D plan for a temporary supply of a non-formulary medication you are already using when first enrolled in the plan.
If one of your brand-name medications is dropped during the plan year when a new generic or alternative medication is added to your formulary or in extreme situations such as when the FDA immediately halts the use of a drug for safety reasons -- your Medicare Part D plan can make the change immediately -- without notifying you. However, if your medication is replaced with a medication that has been on the market (not new), your plan must provide you with a 30-day notice of the formulary change or a 30 day refill.
Related Topic: Asking your Medicare Part D plan for a temporary supply of a non-formulary medication you are already using when first enrolled in the plan.
This article is dealing with the topic of mid-year formulary changes - such as when your formulary medication is no longer covered by your Part D drug plan. However, if you are still in the first 90 days of your Medicare Part D plan coverage and your plan does not cover one of your medications, you may be able to ask your
Medicare drug plan for a one-time, transition
fill or temporary 30-day supply of a medication you currently use.
Remember,
a transition fill is for a medication you are already using and your medication cannot be a drug that is excluded
from the Medicare program. To initiate a transition fill
request, call the toll-free Member Services telephone number found on your
Member ID card. Learn more about what is required to get a one-time transition fill.
Below are five (5) steps you can take when your brand-name Medicare Part D drug is dropped from the plan's formulary:
- Try the generic equivalent
If your brand-name drug is no longer covered, you can first try the generic equivalent and see if the generic equivalent is as effective as your brand-name drug. Some people may find that they are not able to use a generic equivalent because of variations in the drug’s “inactive” ingredients.
- Find an alternative formulary
medication
You can work with your doctor or prescriber to find an alternative or substitute medication that is covered by your Medicare prescription drug plan. For instance, you can ask your doctor about another generic or brand-name medication on your formulary. To assist with your search, you can use our Formulary Browse to see all medications covered by your Medicare plan.
- Ask for a formulary exception
You can also use the 30 days to ask your Medicare Part D plan for a formulary exception or coverage determination whereby you would continue to receive coverage for your existing brand-name medication.
Important: Your Medicare Part D prescription drug plan will not automatically grant a request to cover a non-formulary medication and you probably will need to work with your doctor or prescriber to support your request for an exception. If your formulary exception is denied, you have the right to appeal your plan’s decision. Read more about the appeals process if your Coverage Determinations is denied.
You can click here to read more about Coverage Determinations.
Learn more about mid-year formulary changes in our Frequently Asked Questions.
- Change plans using a Special Enrollment Period
If you cannot use the new generic alternative or another formulary medication
- and you have exhausted the formulary exception process
- and you are outside of the the annual Open Enrollment Period (AEP - ending December 7th) or Medicare Advantage Open Enrollment Period (MAOEP - ending March 31, if enrolled in a Medicare Advantage plan)
- you may wish to consider whether you can take advantage of a Special Enrollment Period and change to another Medicare plan that covers all of your medication and healthcare needs.
(Unfortunately, a Special Enrollment Period is not specifically granted when a brand drug is dropped from your formulary.)
- Compare brand prices using a drug discount card or pharmacy discount program
If you are not able to use a Special Enrollment Period or do not want to change Medicare plans, you may be able to continue purchasing your (now) non-formulary brand-name prescription using a discount coupon or a drug discount card - but, you will need to read the "fine print" associated with any discount programs as often Medicare beneficiaries are excluded from these programs (by law).
Check local pharmacy prices using a drug discount card.
Question: Is my Medicare drug plan required to notify me if the plan is changing their formulary?
Not always. If you were not already receiving coverage for this medication (for example, you have not purchased it once already during this plan year) you may not receive a notification from your plan. In addition, if your brand-name drug is being replaced with a new generic – or if the FDA immediately halts the use of a drug for safety reasons, the formulary change can take effect immediately and without notice.
However, your Medicare Part D plan will provide you with a 30-day notice or a 30-day refill for any other negative formulary change to a medication you are using. For example, your brand-name drug is being replaced with an existing generic, meaning a generic drug that has been covered by your plan in the past.
For further reference, please see your Medicare plan’s Explanation of Benefits document (try Section 4) or review your Medicare plan’s Evidence of Coverage (try Section 6.2) where you should find text such as: “Other changes to drugs on the Drug List: …”
Not always. If you were not already receiving coverage for this medication (for example, you have not purchased it once already during this plan year) you may not receive a notification from your plan. In addition, if your brand-name drug is being replaced with a new generic – or if the FDA immediately halts the use of a drug for safety reasons, the formulary change can take effect immediately and without notice.
However, your Medicare Part D plan will provide you with a 30-day notice or a 30-day refill for any other negative formulary change to a medication you are using. For example, your brand-name drug is being replaced with an existing generic, meaning a generic drug that has been covered by your plan in the past.
For further reference, please see your Medicare plan’s Explanation of Benefits document (try Section 4) or review your Medicare plan’s Evidence of Coverage (try Section 6.2) where you should find text such as: “Other changes to drugs on the Drug List: …”
- Browse Medicare Part D prescription drug plans
- Browse Medicare Advantage plans (MAPD)
- Sign-up for our Medicare Part D Newsletter.
- Still have a question? Click here to let us know.