Living with Formulary Restrictions

When a Medicare beneficiary goes to the pharmacy, they are often surprised when they find they have a medication they can’t get because of a restriction. They don’t always understand they have to have certain paperwork completed by their doctor before the medication can be given to them. When people find they have a formulary restriction on a medicine, they often don’t know what to do so they can continue to take the medication they have been prescribed.

Most Medicare Part D prescription drug plans have medications that have medications with formulary restrictions. They are aware that it takes some by surprise and will do all they can to ensure their members get the medication they need. When they have members with medications with formulary restrictions, they will take the time notify their members.

The Notification and Decision

When a Medicare beneficiary has a medication filled with a formulary restriction, they are notified within days of the issue. When a Medicare Part D prescription drug plan provider mails out a letter, there are specific instructions that have to be followed. These letters are often mailed within 7-10 business days of the medication being filled. Some pharmacists will even tell their clients they need to contact their Medicare Part D prescription drug plan provider about the medication.

When Medicare beneficiaries learn their medication has a restriction, there are different things that can be done. There are some members that don’t want to work with their doctors to have the formulary restriction lifted. When this happens, they may ask their doctor to write a different prescription, one that doesn’t have a formulary restriction. There are others that want exactly what the doctor has prescribed and will notify their doctor of the letter and take the forms to their doctor.

The Form and Determination

As soon as a member decides they want to keep their medication as their doctor has written, they should take their form to their doctors. In the notification letter that was sent from their Medicare Part D prescription drug plan provider, there should be a form for their doctors to complete and fax to the insurance company’s pharmacy benefit manager. If there is no letter to be filled out, there is a specific number the medical staff has to call to give the necessary information.

When the pharmacy benefit manager has received the information they need, they begin the process of ensuring the medication is safe to be taken as written. This is a process that doesn’t take a great deal of time. When all the information is submitted correctly, the determination can be made within 7-10 business days after the submission. This ensures the patient doesn’t run out of a crucial medication their body has become accustomed to.

The Acceptance or Rejection

After a Medicare Part D beneficiary has all the information submitted to the pharmacy benefit manager, they will get notification of the decision. These notifications are normally mailed to the address they have on file. When people get their response, they know what they need to do next.

Any Medicare beneficiary that has received permission to continue taking the medication as prescribed will be able to refill their medication for the duration of the plan year. There are some cases that formulary restrictions have been lifted for as long as the member was with that prescription drug plan provider.

Unfortunately, there are some Medicare beneficiaries that receive notification their formulary restriction request was denied. Many of these rejections happen because some information was omitted by the doctor’s office. There are other cases that a rejection was caused by a doctor not offering sufficient reasoning for the diagnosis and treatment or didn’t try other alternatives. When this happens, the Medicare beneficiary can have their doctor resubmit the information or request a coverage determination.

Formulary restrictions are not put in place to make a member’s life hard. They are put in place to ensure they are given the medication they need to heal without fear of abusing it. No matter what restriction has been placed on a medication, it can be lifted. If at any time a Medicare beneficiary feels their request has been denied unfairly, they can request a coverage determination, file a grievance with their Medicare prescription drug plan or contact Centers for Medicare and Medicaid Services directly.


Nov. 8 13'

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