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Medicare Part D Formulary Changes

Rx Bottle States Reform - Tied to Piggy BankMedicare formulary changes for may cost you

For the most part the Medicare Part D drug program has been beneficial for people who would otherwise not be able to afford the high cost of medications.

Health care reform legislation means that Medicare Part D formulary changes that took place in 2012 may cost you.

Legislation that became effective January 1 2011 required that companies that manufacture brand-name prescription drugs give a discount on those drugs to Medicare.

If companies do not agree to give Medicare a discount those drugs will no longer be paid for by Medicare.

This means that medications once included in Part D formularies  may not be included due to this reform. Changing to another plan to get these drugs will not be an option.

If a discount is not offered to Medicare none of the Part D plans or Medicare Advantage plans with Part D included will include the drugs.

What if my drugs are not covered by Part D?

If Medicare formulary changes affect your ability to obtain certain medications through your Part D or Medicare Advantage plan you do have a couple options.

The first option is to pay for the medications out-of-pocket. Certainly not a great option for seniors on a fixed income. But those people with the means to pay out-of-pocket have that choice. That option will not include any discounts due to being enrolled in a Part D or Advantage plan that includes drug coverage.

If individuals continue to pay for those drug on their own the costs will not count toward the Medicare Part D coverage out-of-pocket spending. This means if you are in the donut hole you can’t count any of the expenses toward qualifying you to reach catastrophic coverage cost-sharing.

If a drug maker does not agree to give Medicare a discount and their drugs are also made by another manufacturer the pharmacy will change your prescription to the manufacturer who agreed to the discount. If this happens you will continue to receive your medications.

Another option is to speak with your doctor to find out if another medication that is included in your plan’s formulary will work for you. Plans are required to notify members of any formulary changes  through a notice called the Annual Notice of Change. With this advance knowledge you can meet with your doctor prior to the changes taking effect.

 Anticipating change

It’s best to be proactive to avoid any surprises. Here a couple suggestions to help you be prepared:

  • Watch your mail for any notifications that will effect your plan’s formulary.
  • If you are taking medications that will not be covered speak with your pharmacist to see if the drug is manufactured by another company.
  • If no other manufacturer makes the drug then make an appointment with your doctor to discuss any other drugs that may work for you.
  • Worst case scenario is to pay for the drug out-of-pocket.



In the short term it would seem that Medicare Part D formulary changes were enacted to punish those on Medicare. But don’t forget that the vast majority of drug manufacturers are on board with giving Medicare a discount.

My guess  is that Medicare has probably been paying top dollar to many drug makers all along. If those that did not agree to the discounts find that they are losing sales and effecting profits perhaps they will re-think their position.

8 comments

  1. I want to read the formulary myself to see what tier my medications are in so I can figure the cost. Where is the formulary that I could read??

  2. James, In my response to your question on 12/6/2010 I provided you a link to the Humana Walmart-Preferred Rx Plan formulary. If this is the formulary you are referring to click Here to view the web page where you will find a link to that formulary specific to your location. Formularies vary based on location.

  3. Where do I go to find the cost of prescription drugs?

  4. Vickie, If you have or are considering a specific Part D Plan, locate the name of the drug in the plan’s formulary (drug list) to determine which tier it falls into. Check you plans benefits guide to see copay information. If a coinsurance (percentage) amount is listed or if you will have to cover the cost because you have yet to meet a deductible, you will need to contact your local pharmacist. Let them know which plan you have and they will be able to give you the cost. If the drug is not covered in the formulary, it would be wise to shop several pharmacies as the price may vary. If you are shopping for a plan keep in mind that 2011 Medicare Part D formularies are the key to choosing the right plan. I hope that helps.

  5. If I dont have a part D plan does Hectorol get covered by regular Medicare and where can I see the Medicare formulary, without a part D plan

  6. Joseph, Original Medicare only offers coverage for Part B drugs. I’m not sure that Hectorol falls into that category. If you are on dialysis check with your doctor to see if it qualifies as a Part B covered drug. If it does not, you would need to have part D coverage to receive a price less than retail. Generally, medications received through a retail pharmacy are Part D drugs.

  7. I need to know why one month my prescription co-pay was $8 and the next it was $13.56? Thanks for an answer.

  8. Ann, The information you provided will not allow me to answer your question. there are many variables as to why a copay amount can change. I would recommend that you call customer service for your Part D provider and pose the question to them. Sorry I’m not a greater help.

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