Notices that plans must give you if they make changes during the year

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If your Medicare Advantage plan (Medicare private health plan) or Medicare prescription drug plan makes any changes during the plan year they must notify you.

Network provider changes:

Most Medicare Advantage plans have networks of doctors, hospitals and other providers. You typically pay less if you see providers that are in your plan's network. Most people can only change their plan once a year during the Fall Open Enrollment Period, but providers can leave a plan’s network at anytime.

When a provider is leaving a plan’s network, the plan must try and send all the plan members who use that provider a written notice at least 30 days before the provider leaves the network.

Mid-year formulary changes:

If your drug plan makes changes to its formulary during the year, you have certain rights depending on why the plan made the change.

If a drug is declared unsafe by the Food and Drug Administration (FDA) a plan can remove the drug from their formulary at anytime. When a drug is removed by the FDA the plan must notify anyone who might be affected.

If the plan is making maintenance changes, they must give you 60 days notice or provide you with a 60 day transition fill. Maintenance changes include covering a generic drug instead of a brand-name drug or adding quantity limits for drugs that the FDA adds warnings to, and making formulary changes based on clinical best practices and safety concerns.

If your plan is making non-maintenance changes, which is any other change, and you are already taking the drug you must be allowed to continuing taking that drug for the rest of the year as long as it is medically necessary. Your plan must also send you a notification in the mail stating that the drug is no longer on their formulary but it will be covered for you for the rest of the year.

When a plan makes any of these changes they are required to update both the online and print version of their formulary. If you are going to be affected by any of the changes to your plan’s formulary, they must send you a copy of the updated formulary in the mail.


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