. Your Medicare Part D prescription drug plan's formulary or drug list can change throughout your coverage year - with approval from CMS (the Centers for Medicare & Medicaid Services).
However, your Medicare Part D plan will generally provide you with at least a 30-day notice of any negative coverage changes and cannot drop a medication you are currently using or a drug for which the plan is already providing you coverage -- unless
the medication is being dropped for reasons of:
Key Point about the introduction of new generics during the plan year.
- safety (such as a recall),
- regulations (such as a change in FDA approval), or
- a brand-name drug you are currently using is being replaced with a new generic equivalent (the most common change).
Your Medicare drug plan (stand-alone Medicare Part D plan (PDP) or Medicare Advantage plan that includes drug coverage (MAPD)) is not required
to notify you when dropping coverage for your brand-name drug when a new generic equivalent is introduced and you may notice in your Medicare plan's Evidence of Coverage (EOC) document 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."
"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"
For more information about your Medicare plan, please refer to your plan's Explanation of Coverage document - for example, you may find information in Chapter 5 "Using the plan’s coverage for your Part D prescription drugs", Section 6.2 "What happens if coverage changes for a drug you are taking?". If you cannot find your EOC document, please call your plan's Member Services department and request an EOC.
If your brand-name medication is being replaced by a generic
(often a newly released generic drug), you can:
As noted - you may not have much warning about an upcoming formulary change.
- Try the generic medication and see if the generic equivalent is as effective as your brand-name drug. Some people may find that they are not able to use a generic equivalent because of the generic’s “inactive” ingredients.
- Work with your doctor or prescriber to find an alternative or substitute medication that is covered by your Medicare prescription drug plan. For instance, you can ask your doctor about another generic or brand-name medication on your formulary. To
assist with your search, you can use our Formulary Browser to see all
medications covered by your Medicare plan.
- You can also ask your Medicare Part D plan for a formulary exception or coverage determination whereby you would continue to receive coverage for your existing brand-name medication.
Important: Your Medicare Part D prescription drug plan will not automatically grant a request to cover a non-formulary medication and you may need to ask your doctor to get involved to support your request for an exception. Also, if your request for a formulary exception is denied, you may wish to consider filing an appeal or a number of appeals to get your drugs covered for the remainder of the plan year.
- If you cannot use the generic alternative or another formulary medication - and you have exhausted the formulary exception process, you may wish to consider whether you can take advantage of a Special Enrollment Period and change to another Medicare plan that covers all of your medication and healthcare needs.
- If you are not able to use a Special Enrollment Period or do not want to change plans, you may be able to continue purchasing your now non-formulary brand-name prescription using a discount coupon or a drug discount card - but, you will need to read the "fine print" associated with any discount programs as often Medicare beneficiaries are excluded from these programs (by law).
if you search our Formulary Browser
or Drug Finder
or your Medicare plan’s online formulary
or even the plan finder on Medicare.gov, you will not see an indication that a plan’s formulary is changing. These online formulary tools only reflect the current formulary status (and not upcoming drug list changes).
So how will you know when one of your brand-name drugs is no longer covered by your Medicare drug plan?
Your Medicare plan’s website should be updated with any current formulary changes - or you may learn about the change when you go to a pharmacy to fill your prescription - or your plan may send you a written notification about a formulary change that will affect you.
Your Medicare Part D plan's document may be titled "Formulary Update" and could state something such as:
"This is a listing of the changes that have
occurred in our formulary."
Once you open your Medicare prescription drug plan's formulary change document, you might find text such as:
review these changes and call [your Medicare Part D plan] at the telephone
number listed in your Comprehensive Formulary if you have any questions. You
can obtain an updated coverage determination or an exception to a coverage
determination by visiting our website at www.[your Medicare Part D plan’s
website].com or by calling the telephone number listed in your Comprehensive
Formulary. Please refer to your Evidence
of Coverage for cost-sharing information.”
Then when you look for a particular drug in the plan's formulary change
document, you might then read:
"XYZ - Drug Removed / Generic Available / Brand
name medication will be removed from the formulary effective 07/01/2015. ALTERNATIVE DRUG(S): ABC-Drug Generic,
biweekly on Tier 3."