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Article: Midyear Formulary (Covered Drugs) Changes
Midyear Formulary (Covered Drugs) Changes
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- Midyear Formulary (Covered Drugs) Changes
Midyear Formulary (Covered Drugs) Changes
By the GWAAR Legal Services Team
Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. During open enrollment, Medicare beneficiaries may pick a Medicare drug plan based on the drug plan’s formulary and what drugs are in each tier.
Typically, clients must make this decision from October 15 – December 7. Then, they have the drug plan throughout the upcoming year. However, what happens if — in the middle of the year — a Medicare drug plan wants to change its formulary, change the drug tier, or place restrictions on the use of a drug? A Medicare drug plan can make some changes to its formulary during the year, yet, the Centers for Medicare & Medicaid Services (CMS) does restrict what changes a Medicare drug plan may make midyear. For example:
(A) Changes not Caused by Medicare Part D Drug Plan – A Medicare drug plan may remove a drug from its formulary at any time if the Food and Drug Administration deems a drug unsafe or a manufacturer removes a drug from the market.
(B) Positive Changes for Beneficiaries – A Medicare drug plan may add drugs to its formulary, place a drug on a lower cost-sharing tier, or remove restrictions on the use of a drug at any time.
(C) Negative Changes for Beneficiaries —
1. Until March 1 of any given year, a Medicare drug plan may not remove a covered Part D drug from its formulary or change what tier the Medicare drug plan placed a drug.
2. After March 1, a Medicare drug plan may make the following two types of changes :
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Maintenance changes to its formulary, such as replacing brand name drugs with new generic drugs, or modifying its formulary because of new information on drug safety or effectiveness; and
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More substantial changes, including the following:
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Remove a drug from its formulary;
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Move a covered Part D drug to a less preferred tier status; or
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Place restrictions on the use of a drug. For instance, a Medicare drug plan may add limits on how often a beneficiary may use a drug.
For these more substantial changes, CMS requires a Medicare drug plan to comply with the following protections:
(1) The Medicare drug plan cannot implement the change until CMS approves the change; and
(2) If a beneficiary has a Medicare drug plan and is currently taking the affected drug, the beneficiary is exempt from the change until January 1 of the next year. This, of course, would provide even more incentive to shop around during the annual open enrollment period.
Copyright GWAAR Legal Services Team, 2018
Last Updated on 5/7/2018