Can I switch Part D plans if my drug is dropped?
Usually not, and that surprises people. Here is what protections you actually have and how to handle a mid year formulary change.
A drug coming off your formulary mid year does not, by itself, let you change plans. That is the frustrating answer and it is worth knowing before it happens.
What plans can and cannot do mid year
Plans generally cannot remove a drug or move it to a higher tier during the plan year without cause. There are exceptions.
- A generic version becomes available, and the plan substitutes it
- The FDA issues a safety withdrawal, which takes effect immediately
- The manufacturer removes the drug from the market
In most other cases you must be notified in advance, and if you are already taking the drug you are usually allowed to continue it through the end of the plan year.
What protections you have
- Advance notice, generally at least 30 days, or a 30 day supply at the old terms
- Continued coverage for the rest of the year in many cases, if you were already taking it
- The right to request a formulary exception with your doctor's support
- The right to appeal a denial through several levels
Start with the exception request rather than assuming you have to change plans or pay cash. Exceptions for a drug you are already stable on succeed more often than people expect, especially when your doctor documents that alternatives have been tried.
When you can change plans
You need a qualifying event. A formulary change is not one. What does qualify:
- Moving out of the plan's service area
- The plan leaving the area or losing its Medicare contract
- Gaining, losing or changing Medicaid or Extra Help eligibility
- Moving into or out of a skilled nursing facility
- A five star plan available in your area, which allows one switch during the year
That last one is genuinely useful and almost nobody knows about it. If a five star Part D or Advantage plan is offered where you live, you may switch to it once during the year outside the normal windows.
What to do right now
- Ask the plan in writing why the drug is no longer covered and whether continued coverage applies to you.
- Have your doctor file a formulary exception, with an expedited request if going without would harm you.
- If denied, appeal. Ask the plan for the appeal steps in writing.
- Ask your doctor whether a covered alternative would genuinely work.
- Check whether a five star plan is available in your area.
- If none of that resolves it, plan to change during Annual Enrollment and price plans specifically on that drug.
Preventing it next time
The Annual Notice of Change in September lists formulary changes for the coming year. Reading it is how you catch a tier change or a drop before January rather than at the pharmacy counter in February.
See reading your ANOC and checking a formulary.
Common follow-up questions
Can I change plans because my drug was dropped?
Not on its own. You need a qualifying event. Request a formulary exception first, and check whether a five star plan is available to you.
What is the five star special enrollment period?
If a plan with a five star rating is offered in your area, you can switch to it once during the year outside the usual windows.
Do I have to be notified before a drug is removed?
In most cases yes, generally at least 30 days in advance, or you receive a 30 day supply at the previous terms.
Want this looked at properly?
We are an independent agency in McAllen serving Hidalgo, Cameron and Starr counties. No cost to talk it through.
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