Can a Part D Drug Plan suddenly refuse to pay for a medication?

Ask Lance


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Dear Lance,

In September, I went to fill a prescription that had been covered all year by my prescription drug plan. The pharmacist said that my plan would no longer cover this medication. I thought that the plan’s formulary couldn’t be changed for the entire calendar year. Are they allowed to do this?

Upset

Dear Upset,

I can understand how this situation is distressing to you. It is difficult for me to answer the question as to why your medication is no longer covered by your plan without more information.

During the year, a Part D plan might make changes to its formulary (list of covered medications) — dropping some from coverage or adding some it hasn’t covered before — according to Medicare regulations. If the change involves a drug you’re currently taking, the plan must take one of two actions:

• Send you a written notice at least 60 days before the change takes effect; or

• At the time you request a refill, notify you of the change in writing and provide a 60-day transition supply of the drug under the same terms as before.

Changes to the formulary must be approved by CMS (Centers for Medicare and Medicaid Services). Your plan cannot stop covering a medication that the plan has been providing to you except in the following circumstances:

• The medication has been declared to be unsafe and the Food and Drug Administration has changed its approval of the medication or has recalled it;

• The manufacturer has stopped producing it; or

• The brand name medication that you have been using has been replaced with a generic equivalent.

If any of the following changes affect a drug you are taking, the change will not affect you until January 1 of the next year if you stay in your current plan:

• Your drug has been moved to a higher cost-sharing tier;

• New usage restrictions such as quantity limits or prior authorization are added on the use of your drug; or

• Your drug is removed from the formulary but not because of a sudden recall or because a new generic drug has replaced it.

Your Medicare Part D rights

If you have a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan, you have the right to:

• Receive “coverage determination” – a written explanation from your plan about your benefits; including whether a particular drug will be covered, your costs for drugs; any coverage requirements (such as drugs that require the plan’s prior authorization); and requirements for making coverage exceptions;

• Ask for exceptions to drugs not covered by your plan’s formulary;

• Ask for exceptions to waive plan coverage rules (like prior authorization or quantity limits); and

• Ask for a lower copayment for higher-cost drugs if you or your prescriber believe you cannot take any of the lower-cost drugs for the same condition.

SHINE (Serving Health Insurance Needs of Elders) is an award-winning statewide volunteer program that provides free, unbiased and confidential counseling and information for people on Medicare, their families and caregivers. SHINE is a program of the Florida Department of Elder Affairs and is administered in partnership with the state’s 11 Aging and Disability Resource Centers (ADRCs). In Brevard County, our ADRC is the Senior Resource Alliance, located in Orlando. 

To contact a SHINE volunteer counselor for confidential and unbiased assistance, call the Elder Helpline toll-free at 1-800-963-5337, or call 321-752-8080 locally. SHINE has 12 counseling locations throughout Brevard County. Counselors can assist you by telephone or in person. To find a SHINE counseling site near you, go to floridaSHINE.org or call the telephone numbers listed above.