What should I do if my Medicare plan drops a doctor or drug?

A plan may change a formulary, medication tier, prior authorization rule, pharmacy network, provider network, or service area. Those changes do not all create the same rights or deadlines. Call the plan using the number on your membership card and ask for the change in writing. For a drug issue, ask whether the medication is no longer on the formulary, has moved to a different tier, needs prior authorization, or has another utilization-management rule. For a doctor issue, confirm the provider's network status with both the plan and the doctor's office.

Keep the plan notice, your Medicare Summary Notice or Explanation of Benefits, the names of anyone you speak with, and the date of every call. That record can make it easier to request an exception or appeal a coverage decision. If you are reviewing other drug plans, our Medicare Part D guide explains how formularies and plan drug coverage work.

Ask your prescriber whether a covered alternative is clinically appropriate. If it is not, you, your prescriber, or an authorized representative can request a formulary exception. You can also request a tiering exception when the issue is the cost-sharing tier rather than the drug's absence from the formulary. CMS explains that the prescriber must provide supporting information showing why the requested drug or exception is medically necessary.

Ask the plan how to submit the request, whether an expedited decision is available, and what temporary or transition options may apply while the request is considered. If the plan denies the request, ask for the written decision and follow its appeal instructions. Before choosing a different plan, use our Part D coverage overview and verify your medications, dosage, preferred pharmacy, and estimated costs with the plan or Medicare Plan Finder.

First ask whether the doctor has actually left the network for your specific plan. A provider may participate in one plan option but not another, and online directories can lag behind current contracting information. If the provider is out of network, ask your plan whether it has a continuity-of-care policy, especially if you are in an active course of treatment. Ask how long any approval could last, what records are needed, and whether you need prior authorization before continuing care.

Do not assume that a doctor leaving a network automatically gives you a Special Enrollment Period. Medicare says that significant provider-network changes may be evaluated as exceptional circumstances on a case-by-case basis. If the plan cannot continue the care you need, compare the provider network, drug coverage, premiums, cost-sharing, and out-of-pocket maximum before making a change. Our Florida Medicare Advantage switching guide explains the main plan-change windows, and our Original Medicare versus Medicare Advantage comparison can help you understand the broader coverage tradeoffs.

You can appeal if Original Medicare, a Medicare Advantage plan, or a Medicare drug plan refuses to cover or pay for a service, supply, item, or drug that you believe should be covered. The appeal process differs by coverage type, so use the instructions in the written decision rather than relying on a general deadline. For a Part D drug decision, a denied exception request includes information about requesting a redetermination.

You may also have a chance to make a plan change outside the usual enrollment periods after certain events, including moving, losing other qualifying coverage, plan termination, plan non-renewal, or another qualifying circumstance. Review our Special Enrollment Period guide and Annual Enrollment Period checklist before you make an enrollment decision. The applicable window depends on the event, and a plan representative or 1-800-MEDICARE can help you confirm whether you qualify.

Make a current list of your doctors, specialists, hospitals, prescriptions, pharmacy, and upcoming care. Save the plan notice and any written coverage decision. Ask your prescriber about a covered drug alternative or supporting statement if you are requesting an exception. Ask your plan about provider-network options, continuity of care, prior authorization, and appeal instructions. If you are considering a new Medicare Advantage or Part D plan, confirm that the plan serves your address and includes your doctors, medications, and preferred pharmacy before you enroll.

For a one-on-one explanation of the plan choices available in your area, you can schedule a free Medicare consultation. A licensed specialist can explain plan rules and compare available options, while your clinician remains the right source for medical treatment recommendations and supporting documentation.