At the start of each new year, your medications may be covered differently than they were before. Some drugs move to different cost tiers. Others may have new approval steps. Your plan's covered pharmacy network may shift. It's worth checking now whether your medications will be covered the same way, or whether changes are coming.
Your Formulary May Have Changed
Medicare health and drug plans update their coverage each year. A plan's list of covered drugs is called a "formulary." Plans choose which drugs to include, which tier each drug is in (determining your cost), and what approval rules apply.
This means your medication might:
- Stay on the same tier (cost level) for 2027
- Move to a higher or lower tier
- Require a new approval step you didn't need before
- Come off the formulary entirely
Your plan should send you two important documents each fall. One is your "Evidence of Coverage" (EOC). The other is your "Annual Notice of Change" (ANOC). These documents tell you what's different in 2027. Reading them shows you exactly what has shifted.
Pharmacy Networks and Formularies Are Separate
Formulary changes and pharmacy network changes are two different things. A formulary change means a drug's coverage status or tier shifts. A network change means the pharmacies where you can fill prescriptions change.
Your medication might stay on your plan's formulary but no longer be available at the pharmacy you've been using. If your pharmacy leaves the plan's network, you may still be able to fill prescriptions there. However, the plan may not cover the prescription at that pharmacy, or your out-of-pocket costs may be higher. Your drug stays covered by the plan, but plan coverage at that specific pharmacy may end. Check both your formulary and your plan's pharmacy directory to see what's in place for 2027.
How Plans Control Costs: Prior Authorization, Step Therapy, and Quantity Limits
Your plan may use three tools to manage coverage and costs.
Prior Authorization is approval you need before a drug is covered. Your prescriber submits information showing the drug is medically necessary. They explain that you meet the plan's requirements. The plan reviews this and decides whether to approve. Approval is not automatic. It depends on the plan's criteria and your specific situation.
Step Therapy means the plan asks you to try a lower-cost drug first. Your plan may require you to try this less expensive option before covering a more expensive one. Your prescriber can request an exception. They explain why you need to skip this step. But the plan makes the final decision.
Quantity Limits cap how much of a drug you can receive. A plan might cover only 30 tablets per month, for example. Your prescriber can ask the plan to override this limit if you need more. But the plan decides.
Any of these rules can be new for 2027 or different from 2026. Check your Annual Notice of Change to see whether your medications have new requirements.
What to Do If Your Drug Isn't Covered or Has New Restrictions
If your drug isn't on your plan's formulary for 2027, or if it now has prior authorization or step therapy, you have options. You don't have to accept the change without exploring alternatives.
You, your prescriber, or someone acting on your behalf can ask the plan for an exception to its rules. Your prescriber will need to submit a statement explaining why the drug is medically necessary for you. The plan reviews this information and decides.
When the plan receives your prescriber's supporting statement, it has specific timeframes to respond. For expedited requests, when a delay could harm your health, the plan must decide within 24 hours. For standard requests, the plan has 72 hours. You can get an answer fairly quickly. Keep in mind that the plan may approve your request or may not. The decision depends on your circumstances and the plan's medical policies.
2027 Negotiated Drug Prices
Starting January 1, 2027, 15 additional drugs will be available at negotiated prices under Medicare Part D. These are common medications for diabetes, asthma, heart disease, and other chronic conditions. Medicare negotiates these prices with manufacturers each year.
When a drug qualifies for a negotiated price, Part D plans generally must include it on their formularies. Applicable coverage rules may still apply. You may still need to meet prior authorization or step therapy rules. The negotiated price itself does not determine your individual cost-sharing. Your copay, coinsurance, or tier placement is determined by your specific plan. Costs may vary from plan to plan.
How to Check Your 2027 Coverage
Open Enrollment runs from October 15 through December 7, 2026. During this time, you can compare 2027 coverage by searching your medications in the Medicare Plan Finder.
Here's what to do:
- Search for each of your medications by exact name and dosage in the Plan Finder
- Look at whether each drug is on the 2027 formulary
- Note the tier it's in
- Check whether prior authorization or step therapy applies
- Compare estimated annual prescription costs across plans
- Verify that your preferred pharmacy is in each plan's network
- Compare plans side by side if you find gaps in your current plan
- Make your choice by December 7 if you want new coverage starting January 1
If your current plan covers your medications and you're satisfied with your cost-sharing and pharmacy network, you can stay put. If you find a drug will no longer be covered or coverage has become more restricted, this is the time to look at other plans.
Checking now gives you time to make a thoughtful decision. Once January 1 arrives, plan changes take effect.
What to Remember
Medicare health and drug plans change every year. Before January 1, 2027, search for your prescriptions using the Medicare Plan Finder. Review your plan's Annual Notice of Change. Look for new prior authorization, step therapy, or quantity limit requirements. If a drug isn't covered or has new restrictions, you can ask your plan for an exception. Your prescriber will submit supporting information. The plan will respond within the timeframes set for expedited or standard requests. You have until December 7 to switch plans if your current one doesn't meet your needs. Other enrollment opportunities may apply in certain circumstances, depending on your situation.