Medicare Advantage Plans and Medicare prescription drug plans (Part D) 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.
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 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 instead of a brand-name drug, or changing the tier of a brand-name drug after introducing a generic option
- Adding coverage restrictions 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Note: If a drug is declared unsafe by the FDA and withdrawn from the market, a plan can remove the drug from their formulary at any time.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. 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.