Formulary Restrictions: What are They

Those that are new to using a Medicare prescription drug plan are often surprised to find there are formulary restrictions for some medications. They may be used to paying for their medications cash and not having to deal with these restrictions. There are others that may have just retired and have never had an issue with a formulary restriction. Because they have never heard of it or dealt with a formulary restriction, they don’t know what they are.

A formulary restriction is a restriction placed on a particular medication. These restrictions are placed on medications for many different reasons. Some prescription medications are restricted because the medications can have an adverse effect on a patient if used without diligent care. This is something that many patients don’t know when they are prescribed medications. Many don’t know there’s a restriction until they take the medication to their pharmacy and are told the medication is not covered or there is a restriction.

Who Places Formulary Restrictions

The most alarming thing for a person with insurance to hear is their medication is not covered. That is something that will upset anyone and it may anger them. When a Medicare beneficiary calls their Medicare Part D insurance provider, they often want to know who placed the formulary restriction on the medications and why. The answer is often startling to them.

Any medication on a Medicare Part D prescription drug plan is a Medicare approved medication. That means the Centers for Medicare and Medicaid services has given that insurance provider permission to help members pay for their medication. The formulary restrictions that are placed on certain medications are issued by a board of specialists that’s made up of pharmacists, CMS officials and many others. This panel has studied the effects of these medications on people, what is safe for consumption and what safety precautions are necessary to prevent overuse, abuse and addiction.

Many Medicare beneficiaries automatically assume it’s only the insurance provider that is putting the restrictions on their medications. Many members become frustrated and want to leave their current Medicare Part D prescription drug plan because of the formulary restrictions they have encountered. This isn’t the best reason to leave a prescription drug plan because if one company has that medication listed with a formulary restriction, the other part d plan providers will have it listed with a formulary restriction as well. All Medicare Part D prescription drug plans have to follow the same rules because they are all governed by CMS.

Common Formulary Restrictions

There are many different formulary restrictions that a Medicare beneficiary may encounter. There are some formulary restrictions that happen more than others. Most Medicare beneficiaries will see quantity limits, day supply limits, step therapy and prior authorization when it comes to formulary restrictions. These are fairly simple to work around and remove for the plan year.

Prior Authorization: A medication that has a prior authorization request normally happens to make sure the medication has been prescribed appropriately. There are millions of medications prescribed for people every year. There are some medications that are more expensive or have stronger side effects than others. Because of these things, Medicare wants to ensure the prescribed medication is the best medication for the ailment.

Step Therapy: There are many that are confused when they run into a medication that is part of a step therapy program. When a medication has been listed as part of a step therapy, it reminds a doctor there are other medications available to help with the ailment. The prescribed medication maybe a medication that is more expensive than other options or it could be one that has been on the market for a while and something more effective has been found.

Quantity Limits: A quantity limit is a limit on the amount of a medication that can be given for the duration of a month or 3 month supply. These medications can be highly addictive, very powerful or other things. Those on the CMS regulatory board wants to make sure these medications are taken as they are prescribed and not abused. Many narcotic pain medications have quantity limits on them.

Day Supply Limits: A day supply limit works much like a quantity limit. It’s the amount of medication that can be taken in a single day. If a medication has a day supply limit, the prescription should be written to match the number of pills taken each day to the number of days a medication will be taken. This helps to prevent abuse and overuse of a medication.

There are many other formulary restrictions that people experience. Those that encounter a formulary restriction with their Medicare Part D prescription drug plan should contact their prescription drug plan provider to ensure there is no alternative way they can get the medications. If there is a formulary restriction, a simple conversation with the doctor will get the medications made available to their members. Medicare Part D prescription drug plans are not set up to make anyone unhappy. A Medicare Part D prescription drug plan was created to help those that can’t afford their medications.


Nov. 8 13'

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