Medicare drug plans have a lot of benefits for those that need them. These plans allow members to pay less for medications they may not be able to afford any other time. There are many things that people like about their Medicare drug plan but there some things that can be frustrating. One of the most frustrating things about part D plans can be the coverage determinations and need for exceptions.
There are times there are restrictions placed on medications. These restrictions are placed for many different reasons on different medications. While they can be a hassle to have, they are often placed for a good reason.
Restrictions and Requests
When people find they have a medication with a restriction they are often very irritated. The most common response is, “My doctor is the expert and he/she should determine my restrictions; not the drug company.” While this is a logical reaction, there are equally logical reasons these restrictions have been placed on these medications.
Restrictions can be placed on any type of medication. These restrictions are sometimes designed to prevent an accidental overdose or an interaction with other medications. There are some restrictions that have been placed because other medications are available to try before leaping to a powerful medication. While these restrictions are put in place for a reason, they can be lifted with a reason as well.
When a medication has a restriction placed on it, Medicare members can submit a request to have it taken off. These requests should be placed through Medicare drug plans. Once they have been made, the decision will be made to deny or accept the request. These requests are often very simple to make and they are very successful. With the correct requests made Medicare members don’t have to worry about not being able to get their medications on time.
The Common Restrictions
There are many kinds of restrictions that can be placed on medications. Some of these restrictions are more common than others.
Prior Authorization- A medication that has a prior authorization request on it means that it the doctor needs to review the reason for the prescription. There are some medications that are potent or are a specialty medication and pharmacists want to make sure they are being prescribed for the proper reason. To have a prior authorization restriction lifted, the prescribing doctor has to speak with the pharmacist via phone or complete a form.
Quantity Limit- There are some medications that can become very dangerous to a Medicare member if it’s taken too often. Instead of allowing patients to develop life threatening side effects or addictions, some Medicare drug plans have to place quantity limits on these medications. To have that restriction lifted the prescribing doctor will have to speak with the pharmacist and maybe to the patient to find an alternative medication.
Step Therapy- Step therapy restrictions happen when there is another medication available to treat the same illness. If there is another medication that is effective, pharmacists want to make sure their members know about it. To get the medication exactly as it has been written, the prescribing doctor will have to speak with the pharmacist.
There are many other restrictions for different medications for different reasons. Although it’s something that can be irritating, Medicare part d plans want to ensure the health and safety of their members by following these restrictions.