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Can my Medicare Part D prescription drug plan drop medications from its drug list?


Yes. 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 30 days 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:
  • 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.
Key Point about the introduction of new generics during the plan year.

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.

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 EOC - 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 your brand-name medication is being replaced by a generic (often a newly released generic drug), you can:
  1. 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.

  2. 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.

  3. 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.

  4.  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.

  5.  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).
     » Check local pharmacy prices using a drug discount card.
Please note - you may not have much warning about an upcoming formulary change.

Unfortunately, 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).

However, your Medicare plan’s website should be updated with any current formulary changes - 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:

“Please carefully 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."





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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.