Can my prescription drug plan stop covering my drug?

Trying to foresee the future with your Part D plan is hard, both for you as the consumer and us as your agents.

I receive a lot of phone calls from client's concerned because a drug price has changed, or it is no longer covered. A new drug has been added that their plan does not cover. Your out of pocket costs with your prescription drug plan can be different than what I went over when I first enrolled you.

There are so many reasons this can happen: the carrier has changed the drug cost, the quantity and dosage of the rx is different, the rx itself was replaced by another drug-- and the biggest reason of all is this.

Let's address the big whammy- "My plan has stopped covering my drug!" The first question I will ask is whether the plan or the pharmacy has told you the drug is no longer covered. There is a difference between it not being on their drug list any longer and it being on their drug list but your costs are higher, or it is going towards your deductible.

If the drug is truly no longer covered, yes, the plan is allowed to make the following changes through the course of the year:

• Adding or removing drugs

• Placing a drug in a lower cost-sharing level

• Placing a drug in a higher cost-sharing level

• Replacing a brand-name drug with a generic drug

• Removing utilization management requirements

• Adding utilization management requirements

In general, your plan must notify you at least 30 days before the tier or coverage of your drug changes and they will often recommend a replacement drug for you.

It does stink, but it is something that does happen. If you do receive a notice from your carrier, the best thing to do is reach out to your doctor and see if they can provide you with a substitute medication that will solve the problem.

If you can only take the particular prescription that is being discontinued, your doctor can ask for a medical exception from your prescription drug plan for that drug. They will need to provide proof as to why the alternative medication will not work for you. But, be aware- it is possible that once they agree to the cover the drug, it will be much more expensive (depending on the retail cost of the medication) and listed as a higher tier drug since it is now on their excluded list.

Thank you for reading!