Part D Formulary Changes: How to Check If Your Drugs Are Still Covered

The Short Version

Every Part D plan updates its formulary every year. A formulary is the list of medications the plan covers and at what price tier. Drugs get added, dropped, moved to higher tiers, and sometimes replaced with alternatives. Your 2025 medication coverage is not guaranteed to match your 2026 coverage.

This post walks through how to check your specific plan's current formulary, what to do if your medication got dropped or moved, and when it makes sense to switch plans.

If you want help walking through your specific medications and plan, I'm at (785) 843-0288.

Why Formularies Change Every Year

Part D plans are contracts between private insurance companies and CMS. Each year, the insurance company renegotiates with drug manufacturers, updates its cost projections, and refiles its formulary with CMS. The new formulary takes effect January 1 of the following year.

Changes happen for a few reasons:

• Generic alternatives became available. When a brand-name drug's patent expires, plans often move the brand to a higher tier and add the generic to a lower tier.
• Negotiated prices changed. If a plan negotiated a better deal on one manufacturer's drug, they may prefer it over a competitor's.
• Clinical guidelines shifted. New treatment standards can add or remove drugs from formularies.
• Step therapy or prior authorization rules updated. Your drug may still be covered but now require prior approval or trying another medication first.
• Inflation Reduction Act negotiations. A small but growing list of drugs have Medicare-negotiated maximum prices, which changes plan economics.

Your plan is required to notify you in writing when material changes affect a drug you take. That notice came in the Annual Notice of Change (ANOC) mailed by September 30 each year. Most Lawrence seniors I talk to toss the ANOC unopened. That is the root of most drug-coverage surprises.

How to Check Your Current Formulary in 3 Steps

Do this at the start of every year and any time your doctor prescribes something new.

Step 1: Find Your Plan's Formulary Online

Search for your plan name plus "formulary 2026" or "drug list 2026." Every Part D plan publishes its current formulary on its website, usually in PDF format. You can also call the member services number on the back of your plan card and ask them to mail you a paper copy.

If you are on a Medicare Advantage plan that includes drug coverage, the drug list is usually in a separate "Evidence of Coverage" document from the plan's main benefits summary.

Step 2: Look Up Each of Your Medications

Search the formulary PDF (Ctrl+F on a computer) for each drug you take. Check:

• Is the drug listed? If yes, it is covered. If no, it is not.
• What tier is it on? Lower tiers (Tier 1 and 2) are cheaper. Higher tiers (Tier 3, 4, 5) cost more per fill.
• Does it require prior authorization (PA)? Your doctor has to submit paperwork before the plan will cover the drug.
• Does it require step therapy (ST)? You have to try and fail on another medication first.
• Is there a quantity limit (QL)? The plan covers only a certain number of pills per month.

Compare this to your 2025 situation. If anything changed, you will want to understand why.

Step 3: Check the Pharmacy Network

Formularies are only half the story. The other half is the pharmacy network. Your plan may cover your drug, but the price you actually pay depends on whether you fill it at a "preferred" pharmacy, a "standard" pharmacy, or out-of-network.

In Lawrence, that breaks down roughly like this:

• Dillons Pharmacy is in most major plans, but preferred status varies
• CVS is in most major plans, preferred status varies (CVS owns one major Part D plan, so they are typically preferred there)
• Walgreens is in most major plans, sometimes preferred
• Local independent pharmacies in Lawrence vary significantly by plan
• Mail-order through your plan is almost always the cheapest option for maintenance medications

A simple example: a Tier 2 generic that costs you $10 at a preferred pharmacy might cost $30 at a standard pharmacy in the same city.

What to Do If Your Drug Was Dropped or Moved

If your medication disappeared from the formulary or jumped to a higher tier, you have a few options. None of them are "just pay more without thinking about it."

Option 1: Ask Your Doctor About a Therapeutic Equivalent

A therapeutic equivalent is a different drug that treats the same condition and may be on a lower tier in your formulary. Your doctor can review the list and see if switching to the equivalent makes clinical sense. This is often the easiest fix and saves the most money.

Option 2: Request a Formulary Exception

If the drug that works for you is truly necessary and the alternatives are not appropriate, your doctor can file a formulary exception with your plan. If approved, the plan will cover the drug at the lower tier price. Exceptions get approved when there is a documented clinical reason you cannot use the plan's preferred alternatives.

The process takes a few weeks and involves paperwork from your doctor. Your plan's member services line can tell you exactly what is needed.

Option 3: Use a Discount Card or Manufacturer Assistance

GoodRx and similar discount programs sometimes offer better prices than your Part D plan, especially on Tier 4 and Tier 5 drugs. You cannot combine these with Medicare, but you can choose whichever is cheaper on a given fill.

Drug manufacturers often run patient assistance programs for expensive medications. If your drug has a copay in the hundreds of dollars, it is worth asking the manufacturer if they have an assistance program that lowers your cost.

Option 4: Switch Plans During the Right Enrollment Period

If your current plan no longer fits your medication list, you have three windows to switch:

• Medicare Advantage Open Enrollment Period: January 1 to March 31. Limited to one switch per year, and only for Medicare Advantage plans (not standalone Part D).
• Annual Enrollment Period: October 15 to December 7. The main window to switch Part D plans for the following year.
• Special Enrollment Period: Certain life events like moving, losing employer coverage, or qualifying for Extra Help trigger a SEP.

Outside these windows, you are locked into your current plan until the next enrollment period.

The 2026 Part D Changes Worth Knowing

Beyond formulary changes, 2026 Part D has structural updates under the Inflation Reduction Act.

The $2,000 Out-of-Pocket Cap

This is the biggest change. Your total out-of-pocket prescription spending is capped at $2,000 for the calendar year. Once you hit $2,000, your plan pays 100% of your covered drug costs for the rest of the year. This cap applies across all Part D plans.

Before this cap, Lawrence seniors on specialty medications for cancer, autoimmune conditions, or rare diseases could spend $10,000 to $15,000 per year. The $2,000 cap fundamentally changes the math for people on expensive drugs.

Medicare Prescription Payment Plan (M3P)

New in 2025 and continuing in 2026, the Medicare Prescription Payment Plan lets you spread your out-of-pocket drug costs over the calendar year rather than paying at the pharmacy counter. If you expect high drug costs in any given month, this can help with cash flow. You opt in by contacting your plan.

Insulin Capped at $35

All covered insulin products remain capped at $35 per month copay across all Part D plans. This continues from 2023.

Vaccines at $0

All vaccines recommended by the Advisory Committee on Immunization Practices (shingles, Tdap, hepatitis B, RSV for older adults, and others) are $0 copay under Part D.

The Donut Hole Is Gone

The old coverage gap or "donut hole" no longer exists. You used to hit a phase where your costs spiked before catastrophic coverage kicked in. That is gone. You move through standard coverage until you hit the $2,000 cap, then pay nothing.

A Real Example

Let me walk through a specific scenario so the process makes sense.

Suppose you are a 68-year-old Lawrence resident on two medications: a generic blood pressure medication (Tier 1) and a brand-name diabetes medication (Tier 3).

In 2025, your plan covered both at reasonable prices. You paid $4/month for the blood pressure drug and $47/month for the diabetes drug at Dillons.

In September 2025, you got an ANOC letter from your plan. It mentioned formulary changes but you didn't read it carefully.

In January 2026, you refill both prescriptions. The blood pressure drug is still $4. But the diabetes drug is now $82/month. You are surprised.

Here is what happened: your plan moved the diabetes drug from Tier 3 to Tier 4 as of January 1. The ANOC disclosed this. You are now paying $35 more per month, or $420 more per year.

Your options:

1. Talk to your doctor about switching to a therapeutic equivalent that might be on Tier 2 or Tier 3 on your current plan
2. Check if your current plan has a preferred pharmacy where the new tier pricing is lower (maybe CVS mail-order)
3. Wait until the next Annual Enrollment Period (October 15 to December 7) and compare plans that cover your specific medications
4. If your situation qualifies for a Special Enrollment Period, use it to switch earlier

All four are valid paths. The right one depends on the details of your situation. That is the kind of conversation a 20-minute phone call can sort out.

How I Help Lawrence Seniors With This

When I work with a Lawrence client, the first question I ask is always about medications. Not how you feel about a plan. Not what premium you want to pay. The medications, specifically, come first.

The process:

1. You give me your complete medication list with dosages
2. You tell me your preferred pharmacy in Lawrence (Dillons, CVS, Walgreens, or a local independent)
3. We pull up the available plans and see which ones cover your exact medications at the best total cost
4. Total cost means premium plus expected copays across the year, not just the premium
5. We confirm your doctors are also in-network if the plan is Medicare Advantage

This is the Four Pillar Medicare Review in action. Medications is the second pillar. Doctors is the first. Budget is third. Life situation is fourth.

The whole conversation takes 30 to 45 minutes, and you end with a clear answer about whether your current plan still fits or whether a change makes sense.

FAQ

How often do formularies change during the year?

Mostly at January 1. But mid-year changes do happen, usually when a generic becomes available, when the FDA pulls a drug, or when a manufacturer stops producing a medication. Your plan notifies you by mail when an active medication of yours is affected.

Can I appeal a formulary change?

Yes. Ask your doctor to file a formulary exception with your plan. The plan must respond within 72 hours for a standard request, or 24 hours for an expedited request. If denied, you can appeal. The appeal process has multiple levels.

If I hit the $2,000 out-of-pocket cap, does my premium still apply?

Yes. The $2,000 cap is for drug costs (copays and coinsurance at the pharmacy). Your monthly plan premium continues as normal.

Does the $2,000 cap include Medicare Advantage drug costs?

Yes. The $2,000 cap applies to all Part D coverage, whether you have a standalone Part D plan or drug coverage bundled in a Medicare Advantage plan.

I have Extra Help. Does the $2,000 cap apply to me?

If you have Extra Help (also called the Low-Income Subsidy, or LIS), you already pay reduced or zero copays at the pharmacy. The $2,000 cap does not really affect you because your costs are already below that threshold.

What if my medication is a specialty drug?

Specialty drugs are typically Tier 5. They have the highest copays or coinsurance in a plan, and they often have prior authorization requirements. The $2,000 out-of-pocket cap protects you from unlimited specialty drug costs, but you will still hit the cap faster than someone on Tier 1 generics only.