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Five things you can do when your Medicare drug plan drops your brand-name drug

Category: Formulary Exceptions (Coverage Determinations)
Updated: Jul, 10 2023

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:
  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

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