Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans and Medicare prescription drug plans ( Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. ) must notify you of any changes they make during the plan year. Typical reasons for sending a notice include changes made to your provider network or formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. .
Network changes
A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. If you are enrolled in an MA Plan, you typically pay less when seeing in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. providers.
In-network providers can leave a plan at any time. When a provider leaves a plan’s network, the plan should send all members who see that provider a written notice at least 30 days before the provider leaves the network.
Mid-year formulary changes
You may receive drug coverage through your MA Plan or through a stand-alone Part D plan. If your drug plan makes formulary changes during the year, you have certain rights depending on why the plan made the change.
Specifically, if your plan is making maintenance changes, they must give you 60 days notice or provide you with a 60 day transition refill. Maintenance changes include:
- Covering a generic drug A generic drug is a medication created to be the same as a brand-name drug that is approved by the Food and Drug Administration. It is the same in dosage, safety, strength, how it is taken, quality, performance, and intended use (definition from the U.S. Food and Drug Administration). Generic drugs generally work just as well as the brand-name version but are less expensive. instead of a brand-name drug A brand-name drug is a drug marketed under a proprietary, trademark-protected name. (Definition from the U.S. Food and Drug Administration) , or changing the tier of a brand-name drug after introducing a generic option
- Adding coverage restrictions Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to limit their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy. to a drug
- Removing a non-Part D drug that had been unintentionally included on the formulary
- Making formulary changes based on new clinical guidelines or Food and Drug Administration (FDA) safety concerns
Note: If a drug is declared unsafe by the FDA and withdrawn from the market, a plan can remove the drug from their formulary at any time. Plans should notify affected individuals, but they are not required to give you 60 days notice.
Plans may make other changes that are not considered maintenance changes. If your plan makes other formulary changes, and you are taking an affected drug, your plan must allow you to continue taking that drug for the rest of the year as long as it is medically necessary Medically necessary refers to procedures, services, or equipment that meet accepted medical standards and are necessary for the diagnosis and treatment of a medical condition. . Your plan should send you a notice explaining that you are exempt from the change for the rest of the year.
Plans should send you an updated copy of the formulary in the mail if you are affected by any changes. They should also update accessible formulary information online and in print.