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More Resources: FAQs About Your Plan

Question 1: Will I be able to get the medicine that my doctor and I think is best for me?

Find out if the PDP has a limited list of medicines it will cover (known as a formulary). If someone in your family takes medication for a chronic illness, such as high blood pressure, diabetes, or high cholesterol, make sure that medicine is on the formulary before you select that plan. If it isn’t, and you choose that plan, you will be expected to switch to a different medication or pay for it out-of-pocket. If you are asked to switch, you should discuss it with your health care provider to make sure that you're taking the medication that is best for you.

Find out if the health plan has to pre-approve certain medicines before you can fill the prescription. Many plans require your health care provider to get prior authorization of certain medications before the PDP will pay for them. That means your health care provider must call the PDP for permission to give you a prescription for these medications. Some plans also require you to try a less expensive medicine first before they will pay for the one your health care provider recommends. Check with your plan to understand their authorization process and restrictions in order to avoid a surprise when you get to the pharmacy. And be sure to learn how to request coverage if the PDP will not pay and you feel the medication is important for your health.

Find out how often your PDP changes its formulary. Be aware that even though your medications may be covered at the time you choose your PDP, the PDP may change its list of approved medicines later in the year. If the PDP chooses to take your medication off the formulary or change it to a different tier mid-year, the plan must notify any enrollee who is taking that medication 60 days in advance. You may have to switch to a new medicine if your old medicine is being removed from the formulary because a generic version of the medicine has become available or because of safety concerns. However, if your medicine is being removed from the formulary during the year for any other reason, the plan must continue to cover it for you until the end of the plan year. This is to give you time to talk to your health care provider and determine whether another medicine that the plan does cover will work for you or whether you want to look for another plan that will cover that medication. If your health care provider determines that you cannot switch to a different medicine and you do not want to switch plans, then you need to request a formulary exception (a type of coverage determination) from your plan in order to be allowed to stay on your old medication.