As a Medicare beneficiary, you could one day find that your stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan has removed one or more of your prescription drugs from its list of approved medications. What you can do if your drug is no longer covered depends upon the reason the plan removes your prescription drug from its formulary and when this change occurs.
Check your plan’s formulary
Medicare plans providing prescription drug coverage can select medications to include in their list of covered prescription drugs (called the formulary) and, with certain restrictions set by Medicare, change the formulary. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Plans often change their formularies each year. Although the plan notifies you of changes, it’s generally a good idea to review your plan’s Annual Notice of Change mailed in early fall each year to see if your medications are on the formulary for the coming year and compare your current plan to others available where you live.
Change your plan
If you find out your stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan is planning to stop covering your prescription drug, then it may be a good idea to switch to another Medicare plan with prescription drug coverage. Remember that even though all Medicare plans with prescription drug coverage must cover the same drug categories or classes, each plan can choose which specific medications to include in each category, so a different plan may offer the prescription drug you take.
You can change stand-alone Medicare Part D Prescription Drug Plans or Medicare Advantage Prescription plans during the Annual Election Period (AEP), which runs from October 15 to December 7 each year. You will automatically be disenrolled from your current plan if you enroll in a Medicare plan with prescription drug coverage during the AEP. Note: you are not allowed to change Medicare plans providing prescription drug coverage during Special Enrollment Periods (SEPs) just because your plan stops coverage of your medication.
Formulary changes during the year
Plans may also change their formularies 60 days after the plan’s coverage begins and until the start of the Annual Election Period in October, generally with Medicare’s approval. Maintenance changes to the formulary may affect your coverage if you are taking one of the medications. Maintenance changes include: removal (or change in tier placement) of a brand name drug based upon the addition of a new generic at a lower cost to members; removal (or change in tier placement) of a formulary drug in light of new clinical evidence; adding new utilization management restriction(s) based on a warning issued by the U.S. Food and Drug Administration (FDA); removal of a drug based on an FDA market withdrawal notice; removal of a non-Part D drug mistakenly included on the formulary.
If a maintenance change occurs within the first 90 days of your enrollment in a new plan, you may be covered under the Transition Policy for a time. The Transition Policy requires Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans to ensure that newly enrolled members and members living in institutions have access to non-formulary medications during their first 90 days in a plan. The transition process requires plans to allow a one-time temporary supply (usually limited to a 30-day supply unless the prescription was written for fewer days or unless the individual is institutionalized) of a non-formulary drug. During this time the member, the prescribing physician, and the plan can work out an appropriate change to another medication on the formulary, or request an exception to obtain the non-formulary drugs.
If your medication is no longer covered because the U.S. Food and Drug Administration has recalled your drug, your plan should contact you. For more information about this situation, please see What Happens If Your Medicare-Covered Prescription Drug Is Found Unsafe?
Other types of formulary changes that occur during the year generally do not affect your ability to continue to have coverage the rest of the calendar year for a prescription drug affected by a change if you were already taking the medication before the formulary change occurred.
Changing your prescription drug
When a stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan stops covering your prescription drug, the plan may send you a list of Medicare-covered prescription drugs in the same therapeutic category or class that may be safe to use as a substitute. Be sure to share the list with your doctor to determine if the substitute will be effective and safe for your specific health condition.
Other steps you can take to try to get coverage for your medication
Other than cases in which your prescription drug has been removed from the market and/or determined by the FDA to be unsafe, you also have the right to ask your plan to make an exception if you know the plan has stopped covering your prescription drug. You or your prescriber can request an exception and that the plan cover your medication if you or your prescriber believe you need a medication that is not on the plan’s current formulary. When requesting an exception, your prescriber must provide a statement explaining the medical reason why the exception should be granted.
If a pharmacy informs you that your prescription drug is not covered and you think it may be, you can ask your plan for a coverage determination, which is a written explanation as to whether or not the medication is covered, whether or not you meet the requirements to receive the medication, and if so, the amount you will pay for the medication, and if not, how you can request an exception.
You or your prescriber can request an exception or a coverage determination in writing or by telephone if you have not yet received the medication. If you make a standard request, your plan should respond to your request with its decision within 72 hours of the plan’s receipt of the request. If your prescriber believes that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function, your request will be expedited if you haven’t received the prescription. The plan will notify you of its decision within 24 hours.
If you have already received the prescription drug, you or your prescriber usually must request an exception or coverage determination in writing. The plan will respond in writing with its decision.
You may appeal the plan’s decision if you disagree. You will be provided information on how to appeal in the plan’s letter if the decision is adverse to your request.