Yes. If your prescriptions have changed since you enrolled into your current 2014 Medicare Part D plan, there are several steps you can take:
(1) Check to see if your Medicare Part D plan covers your new medication. This is the easiest step and you only need to review your plan’s formulary or drug list to see if your new prescription is covered by your plan.
If your drug is covered, be sure to check coverage costs and usage restrictions such as Prior Authorization or Quantity Limits. To help you, we have all stand-alone Medicare Part D and Medicare Advantage plan formularies online for easy browsing. You can click here for an example of an online formulary to get you started – this example is for the 2014 AARP MedicareRx Saver Plus plan formulary for California, but you only need to change the state and plan name to review any other plan – you can also choose “MAPD” at the top of the form if you have a Medicare Advantage plan that includes prescription drug coverage.
(2) If you find that your new prescription is not covered by your Medicare Part D plan, you can ask your prescribing doctor to review your plan’s formulary and see if there are any alternative medications or generic equivalents that are covered by your plan.
(3) If you cannot find a suitable alternative medication that is covered by your prescription drug plan, then you can ask your Medicare Part D plan to cover the new prescription by submitting a request for a Formulary Exception or Coverage Determination.
A formulary exception is used when you and your doctor ask your Medicare Part D plan to provide coverage for a non-formulary drug. Your doctor should be prepared to submit a statement explaining why you need this new medication and that there are no other equivalent medications on your formulary. You and your doctor can also ask that your formulary exception request be expedited or given a faster review based on your current health status.
As you might guess, your Medicare plan is not required to automatically grant your formulary exception request. But if your plan denies your request, you have the right to appeal your plan’s negative decision. In fact, you have the right to appeal a negative formulary request decision through a number of different stages. For more information, you can click here to read about Formulary Exceptions and the appeals process (also found at on this site).
(4) Still another alternative is to take advantage of a Special Enrollment Period (if available) and switch your Medicare Part D plan membership to another Medicare plan that does cover your new medications.
Special Enrollment Periods allow you to change Medicare plans outside of the annual Open Enrollment Period (October 15th through December 7th) and are only granted for specific reasons (such as when you move outside of your plan’s service area). You can click here to read more about Special Enrollment Periods. One Special Enrollment Period that is available in a few areas of the country is the 5-star Special Enrollment Period. You can click here to read about the 5-star Special Enrollment Period.