Since 2006, seniors and other Medicare beneficiaries can choose to receive coverage for their prescription drugs by enrolling in either a stand-alone Medicare Part D prescription drug plan (PDP
) or a Medicare Advantage plan that includes drug coverage (MAPD
Although people usually have access to over 20 different drug plans in each state, each Medicare drug plan will offer different coverage for those medications found on the plan's formulary or drug list – and with annual plan changes, it is possible that you find yourself enrolled into a Medicare drug plan that does not cover all of your prescriptions.*
The good news is that if you find your Medicare drug plan no longer affordably covers your prescription needs, the government provides a few opportunities to change drug plan coverage after the December 7th close to the Annual Enrollment Period (AEP
) (that starts on October 15 and continues through December 7 each year).
First, if you are enrolled in a Medicare Advantage plan
you are permitted to leave or change your 2023 Medicare Advantage plan
through March 31st using the Medicare Advantage Open Enrollment Period (MA-OEP
). You can
to learn more about the MA-OEP.
addition, it is also possible to change your Medicare plan (PDP or MAPD) outside the
annual Open Enrollment Period if you qualify for a Special Enrollment Period (SEP)
– such as the 5-Star SEP
(allowing you an opportunity to join a highly-rated drug plan in your area, if available) – or the SEP granted when you permanently move
to another service area – or the SEP granted to people who qualify for the Medicare Part D Extra Help program
or Low-Income Subsidy (LIS).
And new for 2023
is a rather-flexible Special Enrollment Period available to anyone using an insulin product.
Since the Inflation Reduction Act
was passed so late
in 2022 – after Medicare Part D plan providers had already submitted their finalized 2023 drug plan designs – the government is granting a
Special Enrollment Period (SEP) to any Medicare beneficiaries who use an
insulin product and wish to choose a different 2023 drug plan that may offer more affordable insulin coverage. This SEP should be available to an estimated 3.3 million people using an insulin product.
This SEP can be used
at any time throughout 2023 to change enrollment to another Medicare drug plan (PDP or MAPD) – and is only available by calling a Medicare
representative at (1-800-633-4227).
As noted by the Centers for Medicare & Medicaid Services (CMS) in the document, “Additional CY 2023 PDSS Model Guidance Related to Inflation Reduction Act (IRA) Changes to Part D Coverage of Insulin”:
“Since [the government's 2022 Medicare Plan Finder] will reflect Part D sponsors’ insulin benefits and cost sharing as submitted in [the 2023 Part D plan providers'] bids, CMS is granting a Special Enrollment Period (SEP) for Exceptional Circumstances to allow beneficiaries to add, drop, or change their Part D coverage if they find a better option after the 2022 Annual Enrollment Period (AEP). This SEP will be available for all beneficiaries who use a covered insulin product and begins on December 8, 2022 and ends on December 31, 2023. Beneficiaries may use this SEP one time during this period. To utilize this SEP, beneficiaries must call 1-800-MEDICARE so a customer service representative can process the enrollment change. Consistent with current policy, when Part D enrollees change plans mid-year, their True Out-of-Pocket (TrOOP) costs carry over from one plan to the next.”
So, if you find that your 2023 Medicare drug plan does not offer the most economic insulin coverage – you should be allowed one opportunity to change your Medicare plan at any time during 2023.
If you find that your prescription drugs are not covered (or
no longer covered) by your Medicare Part D plan – and you cannot find an
an alternative medication covered by your plan – and you are not able to change Medicare plans – you have the right to
ask your drug plan for a formulary exception
whereby you request that your drug plan covers your non-formulary drug. Your
plan is not required to automatically granted your request and you may
need to work with your prescribing doctor to appeal any denied formulary exception request
– in fact, you have the right to appeal a formulary exception request denial through several levels ultimately receiving a review by an independent group.