Q & A: August 2021

Can Drug Plans Drop Coverage Of Brand Drugs Mid Year?

Q:  My 2021 Part D plan dropped my brand drug from its formulary.  Are drug plans allowed to do this?  If the generic doesn’t work for me, am I allowed to change plans at this time of year?

A: Typically, Medicare Part D plans must continue to cover a prescription medication that is dropped from the plan’s formulary until the end of the year, for enrollees who are already taking the medication.  Medicare does, however, allow Part D plans to replace brand-name prescription drugs with the generic equivalent if one becomes available mid-year.  Plans are not required to notify enrollees in advance when such a change takes place.

If your Part D plan no longer covers your brand name drug, contact your prescribing physician at once about trying the generic.  Doctors are used to this type of request, and you may just want to try a 30-day supply at first to see how the generic works for you.  If the generic works just as well, it can save you money in out-of-pocket costs.  But if it is not as effective, let your doctor know right away and learn if there is an alternative medication on your drug plan’s formulary that you can try.

You can also try asking your Part D plan to continue to cover your current brand name drug by granting a formulary exception.  It will be important for you to work with your doctor who will need to explain to your Part D plan why you are not able to take the generic medication.

It might be possible to change your Part D plan at this time of the year if you can find a Special Enrollment Period (SEP) that applies to your situation.   There is no SEP specially for drugs being dropped from the plan’s formulary.  You can try contacting a local State Health Insurance Assistance Program (SHIP) for free one on one counseling to learn more.