If a drug is removed from a formulary mid-year, what should the plan do?

• A. Do nothing and let members continue.
• B. Immediately cancel member coverage.
• C. Notify enrollees of the change and provide exceptions or alternative options.
• D. Increase premiums.

Answer: (C)

When a formulary drug is removed mid-year, the plan must protect access to needed medications by communicating the change to enrollees and offering ways to continue therapy. The best approach is to notify members about the formulary change and provide exceptions or alternative options, such as approving a formulary exception if the drug is medically necessary, or offering a therapeutically equivalent alternative that is covered, or arranging a temporary continuation for ongoing treatment. This keeps patients safe and allows time to work with their prescriber to switch or seek an exception, rather than leaving them unaware or abruptly without coverage. The other choices miss the essential step of informing members and ensuring continued access through exceptions or alternatives, which is why they’re not appropriate.