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Compare medication coverage rules of different Medicare Part D drug plans

Check Out the Coverage Rules Before Signing Up For a Part D Drug Plan

When looking around for a Medicare Part D, prescription drug plan, coverage for all your medications and how you must pay for them are your primary concerns. However, there is another concern that merits equal attention – that being the plan’s coverage rules for medications. These rules contain requirements that drug plans put into place to control use of medications for safety or cost reasons.

Why is it important to know about coverage rules? These rules can delay the start of a new medication, make it more difficult to get a drug you need or, in some cases, make you pay for the medication if you want to take it. There are three coverage rules. 

  • The most common one is a quantity limit. The drug plan limits the number of pills in a prescription, the number of prescriptions in a month, or the dosage strength. 

One plan sets a limit of 15 pain patches in 31 days. Another plan
limits a medication to treat the flu to 112 capsules in 365 days. 

  • A second coverage rule is step therapy. In most cases, this means that before prescribing a certain medication (usually very expensive), the physician must order a less expensive but proven effective medication. If the individual experiences side effects or other problems, the physician can then step up to or order the more costly drug.

Before ordering a brand-name medication to treat osteoporosis, the
physician must order a particular generic medication.

  • Prior authorization is the third requirement. The physician must contact the drug plan to get approval before writing the prescription. The plan wants to ensure that the drug is medically necessary and will be used appropriately.

The physician must request prior authorization from the drug plan
before prescribing a popular medication to treat cholesterol.

Every plan applies the rules differently, so find out how they will affect the medications you need. The Medicare Plan Finder is a good place to start because it displays information about coverage rules. You can also learn about coverage rules in written materials that a plan gives you or on its website.

NEW IN 2019: Medicare Advantage will be able to implement step therapy for Part B medications. These are drugs administered in a doctor's office or clinic, including chemotherapy, some anti-rejection or arthritis medications, and others. This will apply only to new prescriptions that the person did not take previously. The plan must provide expedited review for those who have a immediate need for the medication. 

Last updated: 09-20-2018