Medicare Part D Formulary Changes: What to Do When Your Drug Is No Longer Covered
Part D plans can change their formularies every year -- and your drug may be dropped, moved to a higher tier, or have new restrictions added. Here is what to do when your medication coverage changes.
Medicare Part D Formulary Changes: What to Do When Your Drug Is No Longer Covered
Every fall, Medicare Part D plans send an Annual Notice of Change (ANOC) listing changes to their formulary, premiums, and cost-sharing for the coming year. If your drug is being dropped, moved to a higher tier, or subject to new restrictions, you need to act -- either by switching plans during Annual Enrollment Period (October 15-December 7) or by pursuing a formulary exception.
Understanding Formulary Tiers
Most Part D plans use a 5-tier formulary structure:
| Tier | Drug Type | Typical Cost |
|---|---|---|
| Tier 1 | Preferred generics | $0-$5 copay |
| Tier 2 | Non-preferred generics | $5-$15 copay |
| Tier 3 | Preferred brand-name | $30-$50 copay |
| Tier 4 | Non-preferred brand-name | $70-$100 copay |
| Tier 5 | Specialty drugs | 25-33% coinsurance |
Moving from Tier 2 to Tier 4 can increase your monthly cost by $60-$90 for a single drug.
What Plans Can Change Each Year
Part D plans can change their formularies annually, including:
- Removing drugs: A drug can be dropped from the formulary entirely
- Tier changes: A drug can be moved to a higher (more expensive) tier
- New utilization management: Prior authorization, step therapy, or quantity limits can be added
- Premium and deductible changes
Your Rights When a Drug Is Dropped Mid-Year
If your plan removes a drug from its formulary during the plan year (not at annual renewal), you have protections:
Transition supply: If you're currently taking a drug that is removed mid-year, your plan must provide a temporary supply (typically 30 days) while you work out an alternative.
Special Enrollment Period: If your plan makes a significant formulary change mid-year, you may qualify for a SEP to switch plans.
Requesting a Formulary Exception
If your drug is not on your plan's formulary -- or is on a higher tier than you can afford -- you can request a formulary exception.
How to request an exception:
- Ask your doctor to submit a coverage determination request to your plan
- Your doctor must explain why the requested drug is medically necessary and why alternatives on the formulary are not appropriate for you
- The plan must respond within 72 hours (24 hours for expedited requests)
If approved: The plan must cover the drug, typically at the lowest applicable tier.
If denied: You can appeal through the standard Medicare appeals process.
Step Therapy (Fail First) Requirements
Some plans require you to try a less expensive drug before they'll cover a more expensive one -- even if your doctor has already determined the more expensive drug is appropriate.
Your rights: You can request an exception to step therapy requirements if:
- You've already tried and failed the required drug
- The required drug is contraindicated for you
- The required drug would cause an adverse reaction
Switching Plans During Annual Enrollment Period
The most effective solution to formulary problems is switching to a plan that covers your medications at a lower cost. During Annual Enrollment Period (October 15-December 7), you can switch Part D plans with coverage effective January 1.
How to compare plans: Use Medicare Plan Finder (medicare.gov/plan-compare) and enter all your medications. The tool calculates your estimated annual drug costs under each available plan -- making it easy to find the plan with the lowest total cost for your specific drug regimen.
Manufacturer Patient Assistance Programs
If you cannot afford your medications regardless of plan, most major pharmaceutical manufacturers offer patient assistance programs for Medicare beneficiaries who meet income requirements. Ask your doctor or pharmacist, or visit the manufacturer's website.
We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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About the Author
William Gray
Independent Medicare BrokerUS Air Force Veteran · Florida Medicare Specialist
William Gray is an independent Medicare insurance broker based in Daytona Beach and Palm Coast, FL. A US Air Force veteran (A-10 crew chief, Germany), he spent years in corporate insurance before going independent to serve Florida seniors directly. He has helped more than 1,000 clients across Northeast Florida compare Medicare Advantage, Medigap, and Part D plans — always at no cost to the client.
