CHOICES - Changes to Medicare Part D
There are changes to Medicare Part D that will go into effect in 2019. It’s important that you take note of the changes as you think about your plan selection in the fall.
Medicare part D prescription drug coverage requires use of lower cost drugs when available, however, there are times when the lower cost alternative is not appropriate. An exception to this requirement can be made if a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor documenting the need for an exception.
An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception. A
tiering exception
should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier. A
formulary exception
should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) which the enrollee or the enrollee’s prescriber believes should not apply.
Exceptions requests are granted when a plan sponsor determines that: For
tiering exceptions
, that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both. For
formulary exceptions
, that the non-formulary drug is necessary for treating an enrollee's condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects.
In 2019, eligibility for tiering exceptions is based on lowest applicable cost sharing for the tier containing the preferred alternative, not simply based on name of tiers. Plans may continue to exclude drugs on the specialty tier from tiering exceptions requests. A plan’s dedicated generic tier is now open to the tiering exceptions process.
Previously, Part D plans were permitted to exclude the generic tier from the exception process and had more latitude on cost sharing.
Part D Expedited Substitutions
•
Plans will be able to immediately substitute newly available generics for brand name drugs on the same or lower cost-sharing tier without prior beneficiary notice.
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Plan may provide beneficiaries with
general
notice that mid-year generic substitution may occur and affected enrollees and providers can be notified after the fact.
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The Part D plan that utilizes the general notice will be required to provide 30 days supply of the brand name drug upon beneficiary request.
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Beneficiaries can continue to seek formulary exceptions
