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How a mid-year formulary change can affect your Medicare Part D drug coverage

Category: Monthly Formulary Changes
Published: Mar, 25 2023 04:03:36

Can my Medicare drug plan drop the coverage of one of my prescriptions during the plan year?

Yes.  Your 2023 Medicare Part D prescription drug plan's formulary or drug list can change throughout your coverage year and a drug plan can add new generic or brand-name drugs at any time.

For example, in February 2023, seventy-one (71) prescription drugs were added to one or more Medicare Part D formularies.  The 71 new drugs are represented by 103 new National Drug Codes (NDCs) – meaning some of the 71 drugs have multiple variations or forms (such as multiple drug strengths or variations in packaging).

The bad news:  Medicare drug plans can drop the coverage of your brand-name drug mid-year when the plan begins coverage of a generic equivalent drug.

For example, if you have been using the brand-name drug “AAA” that is a Tier 3 drug with a $47 co-pay – and your Medicare drug plan begins to cover a generic drug “ZZZ” that is the generic equivalent to “AAA”, your plan can drop the coverage of “AAA” and ask that you begin using the generic “ZZZ” (which will not be on a formulary tier higher than the brand-name drug).

On the positive side:  Your Medicare Part D drug plan may now cover a newly-introduced brand-name drug that was not previously available to you back in 2022.  For examples of mid-year formulary changes, please click here to see a chart of the 38 new 2023 generic drugs added in February 2023 to one or more Medicare Part D formularies.

Question:  Is my Medicare drug plan required to notify me about mid-year formulary changes?

Not always.  If your brand-name drug is being replaced with a new generic drug, or if the FDA immediately halts the use of a drug for safety reasons, the formulary change can take effect immediately and without any notice.

However, your Medicare Part D plan will provide you with a 30-day notice or a 30-day refill when your brand-name drug is being replaced with an existing generic.

For more information, please see Section 4 of your Medicare plan’s Explanation of Benefits document or Section 6.2 of your Medicare plan’s Evidence of Coverage (EOC) document where you may find an explanation such as:
"[Your Medicare plan] may immediately remove a brand name drug on our Drug List if [the plan is] replacing [the brand drug] with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions." [emphasis added]
"Also, when adding the new generic drug, [your Medicare plan] may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions [when a new generic equivalent is introduced].  [Your Medicare plan] may not tell you in advance before we make that change—even if you are currently taking the brand name drug"
If you cannot find your rather-lengthy EOC document, please call your plan's Member Services department (using the toll-free number found on your Member ID card) and request that your plan send you another copy of your EOC - or provide you with a website link where you can download an electronic copy.

Question:  What should I do if my brand-name drug is no longer covered because my Medicare Part D plan now covers a newly-introduced generic drug?

If your brand-name drug is no longer covered by your Medicare Part D plan, you can use the 30-day notice period (if available) to:

(1)  Ask your prescriber about trying the generic.

(2)  Check for an alternative formulary drug.  You can work with your prescriber to see if there is an alternative medication already on your plan’s formulary.  To assist with your search, you can use our Formulary Browser to see all medications covered by your Medicare drug plan.

(3)  Ask your plan to cover a non-formulary drug.  You can ask your Medicare Part D plan to grant a formulary exception to continue coverage of your brand-name drug.

Important:  You will need to work with your doctor or prescriber to explain why you are not able to use the generic medication or why no other formulary drug is acceptable.  If your formulary exception is denied, you have the right to appeal your plan’s decision.  You can contact your Medicare plan to learn more about formulary exceptions or appealing the denial of your formulary exception request.

(4)  Consider moving to another Medicare plan that provides coverage of all your prescription and health needs.  Although you have only a limit opportunity to change Medicare plans at this time of year, you may wish to explore possible Special Enrollment Periods (SEPs) allowing you to change plans outside of the annual Open Enrollment Period (AEP - that ended December 7th).  And if you are enrolled in a Medicare Advantage plan, you also have the opportunity to use the Medicare Advantage Open Enrollment Period (MA-OEP) to change Medicare plans through the end of March.

Question:  Besides dropping brand-name drugs from the formulary, what other changes can my Medicare drug plan make during the year?

Your Medicare prescription drug plan can also make the following changes to the your drug coverage during the plan year:
  • change usage management restrictions for a formulary medication (for example changing Quantity Limits),
  • move a medication to a lower cost-sharing formulary tier, or
  • move a drug to a higher cost-sharing formulary tier.
The good news:  Most of these mid-year formulary changes will not affect you during the current Medicare Part D plan year.

Learn more about mid-year formulary changes.

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