Can my Part D plan add prior authorization to my medication mid-year?

Yes, but the change may not affect you this year. As you may know, your Medicare Part D plan’s formulary can change in a number of ways throughout the plan-year, including the addition of utilization management (or drug usage management) requirements, such as whether you are required to use step-therapy or your medications are subject to quantity limits or you need to obtain prior authorization from your plan before your medication is covered.

But, because you are already using this medication before the formulary change, you may be exempted from such utilization management changes that are considered by Medicare as “non-maintenance” changes.

In other words, if your Medicare Part D plan has simply added a prior authorization requirement to one of your existing medications mid-year, you may be exempt from this change for the remainder of the year.

On the other hand, your Medicare Part D plan can make utilization management changes that affect you immediately if there is a legitimate health and safety concern based on the issuance of a new FDA warning.

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