Medigap plans change very little each year. That consistency can be reassuring, especially if you’re managing one or more chronic conditions — you know what your plan covers and what you’ll pay for most services. But unlike a Medigap plan, a Part D prescription drug plan may change significantly each year, which impacts which drugs are covered and their cost.
Annual plan changes are normal for Part D plans, and knowing how to maneuver these changes can help you meet your prescription drug needs and stay within your budget.
Why does my Part D coverage change every year?
Standalone Part D plans are offered by private insurance carriers, and, unlike Original Medicare, their cost and formularies can be adjusted annually. Insurance carriers modify their plans to adjust to changing federal regulations, medication costs, and the need to maintain profit margins. This makes them very similar to individual and family plans. Frequent updates can be frustrating, but are typical for private insurance.
Each year you could see things like out-of-pocket maximum increases, a rise in premiums, and a change to your drug formulary (your drug could no longer be covered, or you could pay higher out-of-pocket costs for it). But not all changes are negative. The Centers for Medicare & Medicaid Services has begun negotiating with manufacturers to reduce the cost of about a dozen drugs each year for Medicare beneficiaries, and, since 2024, instituted an out-of-pocket maximum.
What should you review each year during AEP if you have a chronic condition?
You can change your Part D plan each year during the Annual Enrollment Period, which runs from October 15 to December 7. But the time to make sure your plan still fits your needs is in September when you receive your Annual Notice of Change (ANOC). Your carrier will mail you this document in September with details about your new plan that starts January 1. By reviewing your coverage early, you can be better prepared for Annual Enrollment. Things to look for in the ANOC include:
- Changes in your monthly premium, deductible, or copays and coinsurance,
- If the medications you’re taking are covered after 2027 Medicare Part D formulary changes,
- If your medications have changed tiers (which could increase your costs),
- If your pharmacy is still in-network,
- If there are new utilization management rules (like prior authorization required before getting a drug, step therapy that requires you to try lower-cost drugs first, and quantity limits that reduce the amount of medication you can receive at one time),
- If a less-expensive plan is available (note that 2027 plans will not be available to browse and shop until the beginning of AEP).
You can also look over your plan and change to a different one if you qualify for a Part D Special Enrollment Period. You’ll only be allowed to change during this time if you have special circumstances like moving to a new state or qualifying for financial assistance through a Part D plan for people with low incomes.
What if your medication isn’t on the Part D formulary anymore?
If one of your medications is dropped from your Part D plan, it doesn’t necessarily mean you no longer have access to the drug. One possible way to get it covered is through the formulary exception request process. You can accomplish one of three things through this process:
- Get a nonpreferred drug at the cost-sharing terms of a lower-tiered drug,
- Waive a utilization management requirement (like step therapy),
- Get a drug that is not included in your plan’s formulary.
An exception can be filed by you, your prescribing doctor, or your representative. To apply for an exception, you need to contact your Part D carrier in your member portal or call the number on the back of your plan’s ID card. Many insurers have their own determination request forms you can find online. You or your representative should fill out the form. Your prescribing doctor will need to provide a supporting statement telling the carrier why that drug is necessary for treating your condition better than drugs covered on the plan.
Chronic care management: A benefit many Medigap holders don’t know they have
Another way to ensure you are getting proper care for your chronic conditions is enrolling in chronic care management services (CCM). CCM is a Part B benefit for people with two or more chronic conditions. Some of these conditions can be found on the Medicare chronic conditions list and include diabetes, asthma, bipolar disorder, and stroke. The conditions must be expected to last for at least a year to qualify.
If your healthcare provider offers chronic care management, Part B will pay for your doctor to create a comprehensive care plan (after you’ve met your deductible) that includes your health goals, medication review, and coordination between different specialists. To get CCM, talk with your doctor, who can discuss potential costs and provide written or verbal consent that you want to take part in the service.
When it might be time to reconsider your Part D plan with a chronic condition
If you look over your ANOC and find that costs are going to be too high or your drug has been removed from your plan in 2027, don’t fret. Just because one plan doesn’t fit your needs anymore, there are usually others that do. The Annual Enrollment Period is the time to choose a different standalone Part D plan – and it won’t affect your Medigap coverage. United Medicare Advisors can help you through this process. A licensed agent can take your prescription information and use it to find a plan that includes your medications and pharmacy at an affordable price.
