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Appeals and Exceptions: How Do I Know if My Medicine
is Covered?

Medicare drug plans all have a formulary. The medicines on the formulary are grouped into co-pay tiers, or preferred drug levels. There are often tiers for generic drugs, preferred brand name drugs, nonpreferred brand name drugs, and specialty drugs. The tier a medicine is on determines how much your co-pay will be.

Tell me
more about
formularies.

If your medicine is not on the formulary, coverage will be denied. Your plan can also:

• set limits on how many pills of a certain medicine you can get in a month or a year
• require prior authorization or
• require you to try a less expensive medicine before agreeing to pay for the one your health care provider originally prescribed.

Your plan can make changes to its formulary, like adding or removing medications or changing tier assignments, any time during the year. If a plan decides to remove a medication you are taking from the formulary or change it to a different tier mid-year, the plan must tell you 60 days before it makes the change.

Unless a medicine you take is removed from the formulary because (1) a generic version of the medicine has become available or (2) there is a safety reason, the plan must continue to cover it for you until the end of the plan year. This is to give you and your health care provider time to determine:

• whether another medicine that the plan covers will work for you,
• whether you want to request a coverage determination, or
• whether you want to join a different plan next year—one that will cover the medication you need.

You usually cannot switch to a new plan until the annual open enrollment period, even if your current plan takes your medication off its formulary mid-year.