How the introduction of generic drugs shapes future Medicare Part D formularies

As many people know, Medicare Part D prescription drug plans (PDPs and MAPDs) can update their plan formularies or drug lists throughout the plan year. These updates can include dropping drugs, moving drugs to a different drug tier, and adding new brand-name and generic drugs.

For example, the April 2018 Medicare Part D formulary updates included 737 new drug codes or NDCs representing 486 different medications, with 103 being new generic equivalents (variations of manufacturer, drug-strength, and packaging).

New Generics Replacing Existing Brand-Name Drugs During the Plan Year

Over the months following the introduction of new generics, Medicare Part D plan members may find that their brand-name drug is no longer covered by their Medicare plan - and is instead being replaced with one of the new generics.

What to do when there is a mid-year formulary change and your brand-name drug is no longer covered

(1) If your brand-name drug is no longer covered, you can work with your prescriber to find an alternative medication on your plan’s formulary. To assist with your search, you can use our Formulary Browser to see all medications covered by your Medicare plan.

(2) You can try the generic equivalent and see whether the generic medication works the same for you. Some people may find that they are not able to use a generic equivalent because of variations in the drug’s “inactive” ingredients. If the generic is produced by multiple manufacturers, you may want to evaluate the various generics to determine which one is most similar to the brand, e.g. uses the same inactive ingredients.

(3) You can ask your Medicare Part D plan to grant a formulary exception to continue coverage of your brand-name drug – you will need to work with your doctor or prescriber to explain why the generic medication will not work. 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. The introduction of new generics now may affect your Medicare plan coverage next year

So even if your Medicare drug plan does drop an existing brand-name drug when a newly-available generic is introduced, you may find that the introduction of new generic drugs this year means your Medicare plan may not cover your brand-name drug next year.

For example, a number of new generics were introduced in Spring 2017 and their brand-name equivalents were removed from the plan formulary at the end of the 2017 plan year, meaning the brand-name drugs were no longer covered by the Medicare Part D plan in 2018.

We evaluated four (4) drugs, some with multiple strengths (12 National Drug Codes (NDCs) in total):

Cubicin® (Daptomycin introduced April, 2017)
Emend® (Aprepitant introduced April, 2017)
Kaletra® (Lopinavir-Ritonavir introduced May, 2017)
Strattera® (Atomoxetine introduced September, 2017).

Each of these brand-name drugs had been covered on at least 52 of the 59 available 2017 Medicare PDP formularies. However, since the start of the 2018 plan year, only a handful of Medicare Part D plan still cover all 12 variations of theses brand-name drugs.

For example, the following six 2018 Medicare plans continue to cover all 12 drugs:

First Health Value Plus (second largest PDP formulary—5,313 NDCs)
First Health Part D Premier Plus (third largest PDP formulary—5,312 NDCs)
Aetna Medicare Rx Saver (twenty-first largest PDP formulary—3,496 NDCs)
Aetna Medicare Rx Select (fourth largest formulary—5,274 NDCs)
BlueRx Option II in AL & TN (seventh largest formulary—4,256 NDCs),
Educators Rx Advantage in ID & UT (has the largest PDP formulary –5,983 NDCs)
BlueMedicare Complete Rx in Florida (seventh largest formulary—4,256 NDCs).

And not surprisingly, these six stand-alone 2018 Medicare Part D plans also have some of the largest PDP formularies available.

For more information, you can click here to see a chart of trends in formulary coverage for some of the more popular Medicare drugs and their generic equivalents.

Both our Formulary Browser (you can view all the drugs covered by a single Medicare prescription drug plan) and our the drug finder Drug Finder (you can view all the Medicare drug plans covering a single drug) have been updated with the April 2018 Medicare Part D formulary data.