Do Your Drugs Have Restrictions Under Your Medicare Plan?

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Advice for Medicare Prescription Drug Plans

The 2013 Medicare “Annual Enrollment Period” (AEP) continues until 12/7/12. TV commercials, mailings, seminars are abundant during the AEP, and one subject you should pay specific attention to Plan changes and what restrictions might be placed on any medications that you take.

Medicare Plan insurance Companies may guide you toward taking the generic. How can they do this? Medicare Plans are allowed to have published drug restrictions. These restrictions can include: a drug not being included on the formulary list (not covered except through granted “exception”), “prior authorization”, “quantity limits”, “step therapy” or simply raise the tier level at which the drug is covered.

Formulary List – all plans have a list of formulary drugs, meaning drugs they cover. Once you have confirmed that the drugs you take are on you Medicare Plan’s formulary, look to see if there are other restrictions.

Prior Authorization – the Plan must approve the drug in your situation before they will pay for the drug. Quantity Limits – the number of units (pills) that will be covered in a specific period of time. (e.g. 30 pills in 30 days). Step Therapy – the Plan will cover a lower tier drug (e.g. tier 1, generic) and if there is an acceptable reason you cannot take the lower tier drug, the upper tier drug will then be covered. Some Plans (not all) may require you to take the lesser cost drug first and if it is not workable for some reason, they may cover the more expense drug.

“Exceptions” is a term you should know. If your drug is not covered on a Plans formulary; you may ask, though your doctor, for a “Formulary Exception”. If you need a greater quantity of pills than covered by your Plan, you can request a Quantity Exception. If you have had a reaction to a step therapy drug in the past, you can request a Step Therapy Exception. You will need your doctor’s office to submit this request to the insurance company. If you have any questions, call your Medicare Plan Company.

So, what does all of this mean to you? If you are have currently or are purchasing any Medicare Plan including prescription coverage, review the plan summary and the formulary. Look to be sure your drugs are covered. Review the Plan’s drug restrictions (prior authorization, quality limits and step therapy) and be sure you are satisfied with the way your prescriptions are covered. If you have questions call the Medicare Plan Company in question. Questions about alternative drugs can be directed to your doctor and pharmacist.

Also, you can use as resources: Medicare at www.medicare.gov and our website at www.MRMS-INC.com for various issues including information on Medicare and Medicare Plans.

Written by

Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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