Medicare Drug Plans: Exceptions and Coverage Determinations

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.

Nov. 10 14'
Yes it's cold season again. My first mecidation is Pseudoephedrine it is used for the temporary relief of stuffy nose and sinus pain/pressure caused by infection from the common cold or flu or breathing illnesses such as hay fever allergies and bronchitis. Pseudoephedrine is a decongestant it works by narrowing the blood vessels to decrease swelling and congestion. This mecidation should be taken by mouth with or without food, usually every 4-6 hours as directed by the product package or by your doctor. Do not take more than 4 doses in a day or more than 7 days without first consulting your doctor. Dosage is based on your age, medical condition, and response to treatment. Do not increase your dose to take this drug more often than directed or more than is recommended for your age. If a dose is missed, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual schedule. Do not double the dose to catch up.Side effects include nausea, vomiting, trouble sleeping dizziness, headache, or nervousness may occur. If any of these effects persist or worsen tell your doctor or pharmacist promptly. Precautions before taking this mecidation would be an allergic to pseudoephedrine or any other allergies. Also if you are on other mecidations or herbal products consult your doctor because this could effect the mecidations and possibly increase the risk for serious side effects or cause them to not work completely. Some mecidations that may interact with this drug include stimulants such as caffeine, dextroamphetamine, metamphetamine, herbal products like ephedra/ma huang, bronchodilators such as albuterol. You should not take this mecidation if your are taking MAO inhibitors or have used MAO inhibitors in the past 2 weeks. Pseudoephedrine may also decrease the effectiveness of blood pressure mecidations. If any of these apply consult your doctor as soon as possible. Ibuprofen (Motrin) is used to relieve pain from various conditions such as headache, dental pain, menstrual cramps, muscle aches or arthritis. It is also used to reduce fever and to relieve minor aches and pains due to the common cold or flu. Ibuprofen is a nonsteroidal anti-inflammatory drug. It works by blocking your body's production of certain natural substances that cause inflammation. This mecidation is not for the use in children under the age of 2. Dosage is based on age and is usually given every 6 to 8 hours as needed. Side effects include upset stomach, nausea, vomiting, headache, diarrhea, constipation, dizziness, or drowsiness may occur. Warning nonsteroidal anti-inflammatory drugs including ibuprofen may rarely increase the risk for a heart attach or stroke. The risk may be greater if you have heart disease or increased risk for heart disease. This mecidation should not be taken right before or after heart bypass surgery. This drug may infrequently cause serious rarely fatal bleeding from the stomach or intestines. This effect can occur without warning at any time while taking this drug. Stop taking ibuprofen and get medical help right away if you notice any of these rate but serious side effects.Drug interactions involved with this mecidation may change how your mecidations work or increase your risk for serious side effects. Some products that may interact with this drug include aliskiren, ACE Inhibitors, angiotensin II receptor blockers, cidofovir, corticosteroids. This mecidation may increase the risk of bleeding when taken with other drugs that also may cause bleeding. Examples include anti-platelet drugs such as clopidogrel, blood thinners such as dabigratran/enoxaparin/warfarin among others. Consult your doctor if you are on any other mecidations so that they can be reviewed and that they are not any risks if they are taken at the same time.
Jul. 7 15'


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