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Can my Medicare Part D prescription drug plan drop medications from the plan's drug list at any time?

Category: Monthly Formulary changes
Updated: May, 24 2024


Yes - in certain situations.  Your Medicare Part D plan is not permitted to change the plan's formulary or drug list during the first 60 days of the new year - unless the FDA deems the Part D drug unsafe or the drug manufacturer removes the Part D drug from the market.

Then after the first 60 days of your new plan year, your Medicare Part D prescription drug plan's formulary or drug list can change throughout the remainder of 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.
Key Point:  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.  (for more information, please see 42 CFR §423.120(b)(5)(iii))

Please also see our Frequently Asked Question (FAQ) to learn more about notification of mid-year formulary changes:
» Will my Medicare Part D prescription drug plan notify me if the plan's formulary changes during the year?


Question:  What should I do if my brand-name medication is being replaced by a generic?
  1. Try the generic medication and see if the generic equivalent is as effective as your brand-name drug.  Unfortunately, some people may find that they are not able to use a generic equivalent because of the generic’s “inactive” ingredients.

  2. 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 Browser to see all medications covered by your Medicare plan.

  3. You can also 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.  (You can contact your Medicare plan's Member Services department using the telephone number on your Member ID card to learn more about filing a formulary exception.)

    Important:
      Your Medicare Part D prescription drug plan will not automatically grant a request to cover a non-formulary medication and you may need to ask your doctor to get involved to support your request for an exception.  Also, if your request for a formulary exception is denied, you may wish to consider filing an appeal or a number of appeals to get your drugs covered for the remainder of the plan year.

  4. If you cannot use the generic drug alternative or any other formulary medication - and you have exhausted your plan's formulary exception process, you may wish to consider whether you can take advantage of a Special Enrollment Period (SEP) and change to another Medicare plan that covers all of your medication and healthcare needs.  Then, during next year's annual Open Enrollment Period (AEP) that starts October 15th and continues through December 7th, actively search for another Medicare drug plan that provides economic coverage for all of your prescriptions.

    If you are enrolled in a Medicare Advantage plan that includes drug coverage (MAPD), you can use the Medicare Advantage Open Enrollment Period (MA-OEP) to switch to another MAPD that covers your drugs (the MA-OEP only continues through March 31st of every year).

  5. If you are not able to use a Special Enrollment Period or do not want to change plans, you may be able to continue purchasing your now non-formulary brand-name prescription using a discount coupon or a drug discount card - you can also check with the pharmaceutical manufacturer to see if any discount programs are available online - but, you will need to read the "fine print" associated with any pharmaceutical discount programs (PAP) as often Medicare beneficiaries are excluded from these programs as per federal anti-kickback law.



Question:  How will I know about an upcoming formulary change that may affect me?

Unfortunately, if you search our Formulary Browser or Q1Rx Drug Finder or your Medicare plan’s online formulary or even the Plan Finder on the government's Medicare.gov site, 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:
“Please carefully 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"





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