. Your Medicare Part D prescription drug plan's formulary or drug list can change throughout your coverage year - with approval from the federal government's Centers for Medicare & Medicaid Services (CMS).
However, your Medicare Part D drug plan will generally provide you with at least a 30-day notice of any negative coverage changes
and cannot drop a medication you are currently using or a drug for which the plan is already providing you coverage -- unless
the medication is being dropped for reasons of:
- safety (such as a recall),
- regulations (such as a change in FDA approval), or
- a brand-name drug you are currently using is being replaced with a new generic equivalent.
The introduction of new generic drug during the plan year may replace your brand name drug - without prior notification
Your Medicare drug plan (stand-alone prescription drug plan (PDP
) or Medicare Advantage plan that includes drug coverage (MAPD
)) is not required
to notify you when dropping coverage for your brand-name drug when a new generic equivalent is introduced and you may notice in your Medicare plan's Evidence of Coverage
(EOC) document an explanation such as:
"[Your Medicare plan] may immediately remove a brand name drug on our Drug List if [the plan is] replacing [the brand drug] with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions." [emphasis added]
"Also, when adding the new generic drug, [your Medicare plan] may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions [when a new generic equivalent is introduced]. [Your Medicare plan] may not tell you in advance before we make that change—even if you are currently taking the brand name drug"
For more information about your Medicare plan, please refer to your plan's Explanation of Coverage document - for example, you may find information in Chapter 5 "Using the plan’s coverage for your Part D prescription drugs", Section 6.2 "What happens if coverage changes for a drug you are taking?"
If you cannot find your rather-lengthy EOC document, please call your plan's Member Services department and request that your plan send you another copy of your EOC - or provide you with a website link where you can download an electronic copy.
Question: So, can my Medicare plan immediately replace my brand-name drug with a generic drug?
Yes, but . . .
only when the generic drug is newly-introduced - and not an existing generic drug being covered again by your Medicare plan.
As noted in the text above, newly-introduced generics can immediately be substituted for a brand-name drug you are currently using and you may not receive any prior notice about the formulary change from your Medicare plan. (see 42 CFR §423.120(b)(5)(iv))
However, your Medicare Part D plan will provide you with a 30-day notice or a 30-day (1 month) refill for any other “negative” formulary change to a medication you are using.
For example, when your brand-name drug is being replaced with an existing generic, meaning a generic drug that existed before the start of the plan year. During this 30-day period, you should be working with your prescriber to find a different medication covered by your plan. (see 42 CFR §423.120(b)(5)(iii))
Please also see our Frequently Asked Question (FAQ)
» Will my Medicare Part D prescription drug plan notify me if the plan's formulary changes?
Question: How will I know about an upcoming formulary change that may affect me?
if you search our Formulary Browser
or Drug Finder
or your Medicare plan’s online formulary
or even the plan finder on the government's Medicare.gov, you may not see an indication that a plan’s formulary is changing. These online formulary tools only reflect the current formulary status (and not upcoming drug list changes) - and may need a few days to be updated after a formulary change.
Question: So how will I know when one of my brand-name drugs is no longer covered by my Medicare drug plan?
When your formulary changes, your Medicare plan’s website should be updated with any current formulary changes - or you may learn about the change when you go to a pharmacy to fill your prescription (and no longer have coverage of a brand drug) - or your Medicare plan may send you a written notification about a formulary change that will affect you.
Your Medicare Part D plan's document may be titled "Formulary Update" and could state something such as:
"This is a listing of the changes that have
occurred in our formulary."
Once you open your Medicare prescription drug plan's formulary change document, you might find text such as:
review these changes and call [your Medicare Part D plan] at the telephone
number listed in your Comprehensive Formulary if you have any questions. You
can obtain an updated coverage determination or an exception to a coverage
determination by visiting our website at www.[your Medicare Part D plan’s
website].com or by calling the telephone number listed in your Comprehensive
Formulary. Please refer to your Evidence
of Coverage for cost-sharing information.”
Then when you look for a particular drug in the plan's formulary change
document, you might then read:
"XYZ - Drug Removed / Generic Available / Brand
name medication will be removed from the formulary effective 07/01/2015. ALTERNATIVE DRUG(S): ABC-Drug Generic,
biweekly on Tier 3."
For more about mid-year formulary changes, please see:
Federal regulations: 42 CFR §423.120(b)(5) "Provision of notice regarding formulary changes"