It depends on the type of formulary change.(1) No notice of a formulary change when replacing a brand-name drug with a new generic.
Your Medicare drug plan (stand-alone Medicare Part D plan or Medicare Advantage plan that includes drug coverage) is not required
to notify you when dropping coverage for your brand-name drug when a new generic equivalent is introduced. You may notice in your Medicare plan's Evidence of Coverage (EOC) document that your plan notes:
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."
"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"(2) No notice of a formulary change when a formulary drug is removed because the FDA withdraws the drug from the market.
Your Medicare drug plan's documentation will note something such as:
(3) You will receive a 30-day notice for most other formulary changes.
"Once in a while, a drug may be suddenly withdrawn because it has been found to be unsafe or removed from the market for another reason. If this happens, we will immediately remove the drug from the Drug List. If you are taking that drug, we will let you know of this change right away." [emphasis added]
In general, your Medicare Part D plan will give you a 30-day notice if
there is any other type of coverage change for any medications that you have taken
during the plan year (January through December). For example, if you are using a brand-name drug that is being replaced by an existing generic, your Medicare Part D plan will notify you in advance of the formulary change. Where can I see my Medicare plan's formulary changes that impact me?Check your monthly EOB letter and other plan correspondence.
You will notice formulary changes in Section 4 of your Medicare Part D plan's Explanation of Benefits (EOB) letter that you receive every month. Formulary changes on your EOB can include the addition of new drugs, the removal of drugs from the formulary, adding or removing usage management restrictions
on coverage for drugs, and moving a drug from one cost-sharing tier to another. Read more and see examples of change in EOB Section 4: Updates to the plan's Drug List that will affect drugs you take
. Where can I see my Medicare plan's formulary changes that do not directly impact me?Check your plan's website.
If you are not currently receiving coverage for a particular formulary medication, you probably will not know about future formulary changes (for example, that the drug will be dropped from the formulary) - and even if you search your Medicare plan’s online formulary or the Medicare.gov site, you will not see an indication that a plan’s formulary is about to change. However, your Medicare plan's website should show any current formulary changes.Remember:
Unless noted otherwise, you will have at least 30 days notice before any changes take effect unless a serious safety issue is involved (for example, a drug is taken off the market for safety reasons) or replaced with a new generic. And remember you can challenge the formulary change by requesting a Formulary Exception
(a type of Coverage Determination), whereby you ask your plan to cover a non-formulary drug or change how your formulary drug is covered.
Please also see:
» Requesting a Coverage Determination or Formulary Exception
» Prescribing Physician’s Role in Coverage Determination Processes