Medicare Minute
Getting my meds is a hassle!
Over the past few years we have witnessed adjustments to certain medications that are now being restricted by Medicare. Many folks think it’s their drug company plan that is causing these extra prescription hassles. No, it’s not only your drug plan but increasingly it’s Medicare placing guidelines to keep folks from overdosing or abusing certain medications.
Accidental overdose has seen a large increase amongst elderly Americans. Medicare has been monitoring this trend and is restricting the amounts of these potentially harmful drugs that you can order. So how, and what exactly is being restricted? Let’s review.
We have always seen two of these steps when ordering medications, Prior Authorization and Step Therapy. Utilization management, drug restrictions, usage management, or drug restrictions have been a part of Medicare Part D plans as well as Medicare Advantage plans that include Part D.
Some restricted medications merely require your doctor to write a simple note to the drug plan as to why you need this particular medication. This is Prior Authorization. It could be the only drug that works, or the only medication that will work in combination with other meds you are currently taking. Certain combinations of meds can be dangerous and your doctor and pharmacist review to make sure you are not taking dangerous combinations of medications.
Other times drug plans will require that you have Step Therapy with certain medications. This simply means that there could be a lesser expensive medication that the Drug plan wants you to try first before a more expensive medication.
Quantity limits is another category where Medicare governs how much of a particular medication you can order at a time. This list is revised and updated by the Center for Medicare Medicaid Services (CMS). For example many pain medications are being limited to a 30 day supply, or less.
You must remember that a Drug plan can change its formulary (the list of medications it covers) at any time. But the plan must notify you of the changes and offer a supply of your current medication to cover you through the change in the plan. There are rules and the Drug plans are required to offer a medication that will take the place of the medication it is dropping. See your drug plan Summary of Benefits to check the guidelines for your specific plan.
Keep in mind that drug plans are not required to cover over-the-counter medications, cosmetic or hair growth, fertility drugs, sexual enhancement, or weight loss. Also, many plans will not cover compound medications or naturopath products.
Remember that you can change Part D drug plans and Medicare Advantage plans
each year during the Annual Election Period (open enrollment) from October
15th – December 7th. Your new plan will start January 1st of the New Year.
