Medicare Part D: Things People With Cancer May Want to Know

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Things to know once you’ve chosen a Part D drug plan

After you have decided on a Part D drug plan, remember that changes may take place and affect your coverage and cost of your drugs. Here are some things you should watch for:

Formularies can change

Drugs may be added to or taken off a plan formulary. Most drug plans have a formulary (a list of all the drugs covered by the plan, including brand name and generic drugs). In most cases, changes to a plan’s formulary are made at the beginning of a calendar year. But drug plans may add or drop coverage of certain drugs anytime during the year. If a plan removes a drug from the formulary, it must let you know about the change at least 60 days before it takes place.

Plans are likely to make changes to their formularies as new drugs are approved or if a drug is found to be unsafe. If a drug is found to be unsafe, the plan must let you know, in writing, why the drug is being removed from the formulary and give you a list of other drugs that could be used in its place. Plans are not required to let you know when they add new drugs to the formulary.

Some drugs cannot be covered under Part D

Most FDA-approved prescription drugs may be covered by Part D drug plans, but certain types of drugs cannot be covered. These are:

  • Drugs used for loss of appetite, weight loss, or weight gain (except for drugs to treat physical wasting from certain diseases)
  • Fertility drugs
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used to relieve cough and cold symptoms
  • Barbiturates (drugs that may be used to help people sleep or calm them down), unless they are used to treat epilepsy and other serious or chronic health conditions
  • Prescription vitamins and minerals, except pre-natal vitamins and fluoride preparations
  • Non-prescription drugs or over-the-counter drugs
  • Outpatient drugs for which the maker of the drug requires certain tests or monitoring services that must be purchased only from them or the company they choose

If you are eligible for both Medicare and Medicaid, your state Medicaid program may help you pay for some of these drugs if they are medically necessary.

Drug prices can change

A drug plan’s monthly premium is fixed for the calendar year and can’t be changed. But the beneficiary’s cost for a drug from a plan pharmacy or from a mail service can change if a plan changes the status of a drug from preferred to non-preferred or drops coverage altogether. If such a change results in an increase in your out-of-pocket costs, the plan must notify you in writing 60 days before the change takes place.

Also, if the price of a drug changes over the course of a year, the amount you pay out of pocket may change, too. If the cost of a drug goes up during the year, your cost for the drug could go up if you are paying all or most of its cost – for example, in the deductible period or in the donut hole.

You can find out about these price changes in more than one way:

  • Visit the Medicare website (www.medicare.gov)
  • Call 1-800-MEDICARE (1-800-633-4227)
  • Visit your drug plan’s website
  • Call your drug plan’s toll-free customer service line

Participating pharmacies may change

As noted before, all Medicare Part D plans must have a network of pharmacies that take part in their plan throughout the area they serve. These networks must give beneficiaries easy access, taking into account the distance and travel time to the nearest plan pharmacy. The agreements between pharmacies and Part D plans are generally for at least a 1-year period. But pharmacies may choose to drop out of a plan’s network at any time.

You can watch for changes in a plan’s pharmacy network by visiting the plan’s website or asking for a pharmacy directory from the plan’s toll-free customer service line.


Last Medical Review: 01/22/2014
Last Revised: 01/23/2014