Drug plan coverage rules

Note

Call your Medicare drug plan to find out the specific drug coverage rules for your plan.

Medicare drug plans may have these coverage rules:

Opioid pain medication safety checks

Drug management programs

Medicare drug plans monitor the safe use of opioids and other frequently abused medications. Opioid pain medications (like oxycodone and hydrocodone) can help with certain types of pain, but have serious risks like addiction, overdose, and death. These risks are increased when opioids are taken with certain other medications, like benzodiazepines (commonly used for anxiety and sleep).

Starting January 1, 2019, some Medicare drug plans will have a program in place to help you use these medications safely. If you get opioids from multiple doctors or pharmacies, your plan may talk with the doctors who prescribed the opioids, along with the doctor or doctors who prescribed other medications like benzodiazepines, to make sure they’re 

 and that you’re using them appropriately. Your plan will send you a letter in advance if it will limit coverage of your opioid or benzodiazepine medications, or if you’ll be required to get your opioid or benzodiazepine prescriptions from certain doctors or pharmacies.

You and your doctor have the right to appeal these limitations if you disagree with the plan’s decision. If your plan sends you a letter, the letter will tell you how to contact the plan if you have questions or would like to make an appeal. You may be exempt from a drug management program if, for example, you have cancer or you’re in 

 or reside in a long-term care facility.

Safety alerts at the pharmacy

For certain drugs, Medicare drug plans might perform additional safety checks, and will send your pharmacy an alert for review before your prescription is filled. Safety alerts may cover situations like:

  • Possible unsafe amounts of opioids. Your pharmacist or Medicare drug plan may need to review your prescription with your doctor to make sure the medications are safe.
  • First prescription fills for opioids. You may be limited to a 7-day supply or less if you haven’t recently taken opioids.
  • Use of opioids and benzodiazepines at the same time.

If your prescription can’t be filled as written, including the full amount on the prescription, the pharmacist will give you a notice explaining how you or your doctor can contact the plan to ask for a coverage determination. You may also ask your plan for an exception to its rules before you go to the pharmacy to buy the medication, so that your prescription is covered.

Prior authorization

Plans may require a “prior authorization” to make sure certain prescription drugs are used correctly and only when medically necessary. This means before your plan will cover a certain drug, you must show the plan you meet certain criteria for you to have that particular drug.

Quantity limits

For safety and cost reasons, plans may limit the amount of prescription drugs they cover over a certain period of time. For example, most people prescribed heartburn medication take 1 tablet per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication.

If your prescriber believes that, because of your medical condition, a quantity limit isn’t medically appropriate (for example, your doctor believes you need a higher dosage of 2 tablets per day), you or your prescriber can contact the plan to ask for an 

.

Step therapy

Step therapy is a type of 

. In most cases, you must first try a certain, less expensive drug on the plan’s 

 that’s been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, some plans may require you first try a generic drug (if available), then a less expensive brand-name drug on their drug list before you can get a similar, more expensive, brand-name drug covered.

However, if your prescriber believes that because of your medical condition it’s medically necessary for you to be on a more expensive step therapy drug without trying the less expensive drug first, you or your prescriber can contact the plan to request an 

.

Your prescriber can also request an exception if he or she believes you’ll have adverse health effects if you take the less expensive drug, or if your prescriber believes the less expensive drug would be less effective. Your prescriber must give a statement supporting the request. If the request is approved, the plan will cover the more expensive drug, even if you didn’t try the less expensive drug first. 

Example of step therapy

Step 1—Dr. Smith wants to prescribe an ACE inhibitor to treat Mr. Mason’s heart failure. There’s more than one type of ACE inhibitor. Some of the drugs Dr. Smith considers prescribing are higher-cost ACE inhibitors covered by Mr. Mason’s Medicare drug plan. The plan rules require Mr. Mason to use a lower-cost ACE inhibitor first. For most people, the lower-cost drug works as well as the higher-cost drug.

Step 2—If Mr. Mason takes the lower-cost drug but has side effects or limited improvement, Dr. Smith can prescribe the higher-cost ACE inhibitor.

Part D vaccine coverage

Except for vaccines covered under 

, Medicare drug plans must cover all commercially available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

Drugs you get in hospital outpatient settings

In most cases, the prescription drugs you get in a 

, like an emergency department or during observation services, aren't covered by 

. These are sometimes called "self-administered drugs" that you would normally take on your own. Your Medicare drug plan may cover these drugs under certain circumstances.

You'll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Or, if you get a bill for self-administered drugs you got in a doctor's office, call your Medicare drug plan for more information.

If you or your prescriber believe that one of these coverage rules should be waived, you can ask your plan for an exception.