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Know Your Plan: Formularies

Question 5: What rights do I have if my formulary changes?

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 notify you 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 enroll in another plan that will cover that medication next year. 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.

You can also request a coverage determination if your medicine is moved to a different tier with a copay that is higher than you can afford. You can use this form to request a coverage determination is available from Medicare. You may need to ask your health care provider for information to complete the form. If your request for coverage is denied, you can then begin the Medicare appeals process.