As a Medicare Advantage (MA) or Part D plan member, it’s essential to be aware of the notices your plan may send to you during the year, especially if they make changes to their coverage or services. In this article, we’ll discuss the various notices you may receive and what they mean, as well as your rights regarding mid-year formulary changes.

Types of Notices

1. Annual Notice of Change (ANOC): This notice is sent every year in September and outlines any changes to your plan’s coverage, costs, or services for the upcoming year.
2. Evidence of Coverage (EOC): The EOC is a comprehensive document that provides details about your plan’s benefits, costs, and rules. You’ll receive this notice each year after you enroll in a plan.
3. Summary of Benefits (SB): This document is a shorter version of the EOC, providing a quick overview of your plan’s benefits, costs, and coverage limits.
4. Provider and Pharmacy Directory: This directory lists the healthcare providers and pharmacies that are in your plan’s network. You may receive updates to the directory if there are any changes to the network.

Understanding Mid-Year Formulary Changes

If your drug coverage is through an MA Plan or a stand-alone Part D plan, you should be aware of the following maintenance changes your plan can make during the year:

1. Switching from brand-name to generic drugs: Your plan may decide to cover a generic drug instead of a brand-name drug, or change the cost-sharing tier of a brand-name drug after introducing a generic alternative.
2. Adding coverage restrictions: Your plan may impose new coverage restrictions on a specific drug, such as prior authorization, quantity limits, or step therapy requirements.
3. Removing non-Part D drugs: Your plan may remove a non-Part D drug from the formulary if it was unintentionally included.
4. Updating formulary due to clinical guidelines or safety concerns: Your plan may make changes to the formulary based on new clinical guidelines or Food and Drug Administration (FDA) safety concerns.

Your Rights Regarding Mid-Year Formulary Changes

If your plan is making maintenance changes, they must either provide you with a 60-day advance notice or give you a 60-day transition refill. This ensures that you have time to adjust your medications or work with your healthcare provider to find an alternative treatment.

Here’s what you need to know about your rights:

1. 60-day advance notice: If your plan chooses to provide a 60-day advance notice, they will inform you of the changes in writing. This allows you to consult with your healthcare provider and make any necessary adjustments to your medications.
2. 60-day transition refill: If your plan opts for a 60-day transition refill, you will be able to obtain a one-time refill of your medication within the first 60 days of the change. This gives you time to discuss alternatives with your healthcare provider without interrupting your treatment.

Understanding the notices you receive from your Medicare Advantage or Part D plan and being aware of your rights regarding mid-year formulary changes are essential for managing your healthcare effectively. Stay vigilant, review any notices from your plan, and consult with your local NYC Medicare Advisor at Plan Medicare to make informed decisions about your coverage and medications.