Can my Medicare Part D plan change the plan's pharmacy network during the plan year?
Yes. Medicare prescription drug plans (
PDP and MAPD) have the right to add or drop participating pharmacies from the plan's pharmacy network throughout the plan year - or change a pharmacy’s standard / preferred network pharmacy status.
Can I get a Special Enrollment Period to change Medicare Part D plans if my only local pharmacy is dropped from the pharmacy network?
Probably not. Medicare does not provide an established
Special Enrollment Period (SEP) when a Medicare plan changes your pharmacy network (although there is an SEP available when Medicare Advantage plans make
substantial changes to their healthcare network). In most cases, you will need to wait until the Annual Open Enrollment Period (AEP) to change Medicare Part D plans (starting October 15th and continuing through December 7th) - or if you have a Medicare Advantage plan that includes drug coverage (
MAPD), you can use the Medicare Advantage Open Enrollment Period (
MA OEP) to change Medicare Advantage plans (starting January 1st and continuing through March 31st).
However, Medicare does have the ability to grant Special Enrollment Periods for "exceptional conditions" or "extraordinary circumstance beyond [the person's] control" (such as fraudulent enrollment or misleading marketing practices) - and you can telephone a Medicare representative at 1-800-633-4227 and ask whether your situation qualifies you for such an SEP.
For more information about mid-year pharmacy changes, you can refer to your Medicare plan's 200+ page Evidence of Coverage (EOC) document that you were mailed when you enrolled in your plan or you can download from your Medicare plan's website.
For example, you may see a section in your EOC such as:
"What if the pharmacy you have been using leaves the network?
If the pharmacy you have been using leaves the plan’s network, you will
have to find a new pharmacy that is in the network. Or if the pharmacy
you have been using stays within the network but is no longer offering
preferred cost-sharing, you may want to switch to a different pharmacy.
To find another network pharmacy in your area, you can get help from
Customer Service (phone numbers are printed on your Member ID card and
on the cover of this EOC document) or you can refer to the printed
Healthcare Provider and Pharmacy Directory. You can also find
information on our [Medicare plan] website at https://[Your Medicare
plan's website]"
The good news.
Most all Medicare Part D prescription drug plans will have 50,000 to
65,000+ participating pharmacies within the plan’s pharmacy network -
plus often a mail-order option – so even with mid-year pharmacy changes,
you should not have difficulty having your prescriptions filled – and
during the plan year you may even find more local pharmacies being added
to your plan’s pharmacy network.
(As reference, please see: Medicare Prescription Drug Benefit Manual,
Chapter 3 - Eligibility, Enrollment and Disenrollment, Updated: August
19, 2011 (Revised: November 16, 2011, August 7, 2012, August 30, 2013,
August 30, 2014, July 6, 2015, September 1, 2015, September 14, 2015,
December 30, 2015, May 27, 2016, August 25, 2016, June 15, 2017, July
31, 2018 & August 12, 2020)