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.
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
that they are not able to use a generic equivalent because of
variations in the
drug’s “inactive” ingredients.
- Find an alternative formulary
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 may 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. You can click to read more about mid-year formulary changes in
our Frequently Asked Questions.
Requesting a Formulary Exception. If your Medicare Part D
plan’s formulary has changed and a medication you want is no longer
covered (or not covered as before), you have the right to ask your
Medicare plan for a Formulary Exception
(also known as a Coverage Determination). A Formulary Exception is when
you ask that, because of medical necessity, a non-formulary medication
be covered by your plan.
Usually, a statement from your physician or prescriber
is included with your request to establish medical necessity. Remember,
you are not guaranteed that your plan will grant your Formulary
Exception request, but if you receive a negative decision, you can
appeal the decision several times. You can click here to read more about Coverage Determinations. You can also click here to read more about the appeals process if your Coverage Determinations is denied.
- Change plans using a Special Enrollment Period
If you cannot use the generic alternative or another formulary
medication - and you have exhausted the formulary exception process, 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.
- Compare brand prices using a drug discount card
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
- 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.
If you were not already receiving coverage
for this medication
(i.e. you have not purchased it once already during this plan year) you
may not receive a notification from your plan.