Drug plan coverage rules

Medicare drug plans may have these coverage rules:

Medication safety checks

Before the pharmacy fills your prescriptions, your plan and pharmacy perform additional safety checks, like:

• Checking for drug interactions and incorrect dosages
• Checking for possible unsafe amounts of opioid pain medications (like oxycodone and hydrocodone)
• Limiting the day’s supply of a first prescription for opioids to an initial 7-day supply or less
• Limiting use of opioids at the same time as benzodiazepines (like alprazolam (Xanax®), diazepam (Valium®), or clonazepam (Klonopin®)), commonly used for anxiety and sleep

Opioid pain medicine can help with certain types of pain, but have risks and side effects (like dependence, overdose, and death). These can increase when you take opioids with certain other drugs, like benzodiazepines, anti-seizure medications, gabapentin, muscle relaxers, certain antidepressants, and drugs for sleeping problems. Check with your doctor or pharmacist if you have questions about risks or side effects.

If your pharmacy can’t fill your prescription as written, the pharmacist will give you a notice explaining how you or your doctor can call or write to your plan to ask for a coverage decision, including an exception to a plan coverage rule. You may also ask your plan for a decision before you go to the pharmacy, so you’ll know ahead of time if your plan will cover the drug.

Drug management programs

Medicare drug plans and health plans with drug coverage have a drug management program in place to help people at risk for prescription drug abuse. If you get opioid prescriptions from multiple doctors or pharmacies, or if you have a history of opioid-related overdose, your plan may talk with your doctor(s) to make sure you need these drugs and that you’re using them safely.

If your plan decides your use of prescription opioids and benzodiazepines may not be safe, the plan may limit your coverage of these drugs under its drug management program. Your plan may require you to get these drugs only from certain doctors or pharmacies to better coordinate your health care.

Your plan will send you a letter before it places you in its drug management program. You'll be able to tell your plan from which doctors or pharmacies you prefer to get your prescription opioids and benzodiazepines, and give any other information you think is important for the plan to know. After you've had the opportunity to respond, if your plan decides to limit your coverage for these drugs, it will send you another letter confirming its decision.

You and your doctor have the right to appeal if you disagree with the plan’s decision. The letter will tell you how to contact the plan if you have questions or would like to appeal.

Note
The opioid safety reviews at the pharmacy and the drug management programs generally won’t apply if you have cancer or sickle cell disease, are getting palliative or end-of-life care, are in hospice, or live in a long-term care facility.

Important tips if you're prescribed opioids

• Opioid medications can be an important part of pain management, but they also can have serious health risks if misused.
• Talk with your doctor about having prescription naloxone at home. Naloxone is a drug Medicare covers that your doctor may prescribe as a safety measure to rapidly reverse the effects of an opioid overdose.
• Talk with your doctor about your dosage and the length of time you’ll be taking them. You and your doctor may decide later you don’t need to take all of your prescription.
• Talk with your doctor about other options that Medicare covers to treat your pain, like non-opioid medications and devices, physical therapy, acupuncture for lower back pain, individual and group psychotherapy, behavioral health integration services, and more. There also may be other pain treatment options available that Medicare doesn’t cover.
• Tell your doctor if you have a history of depression, substance abuse, childhood trauma or other health and/or personal issues that could make opioid use more dangerous for you.
• Never take more opioids than prescribed. Also, talk with your doctor about any other medications and substances you may be using.
• Safely store and discard unused prescription opioids through your community drug take-back program or your pharmacy mail-back program.

Prior Authorization

Prior authorization limits coverage of a drug to patients who meet certain requirements. Before you can fill the prescription, your prescriber must contact your plan to show the drug is medically necessary and that you meet certain requirements. Plans may also use prior authorization when they cover a drug for only certain medical conditions it's approved for, but not others. When this occurs, plans will likely have alternative drugs on their list of covered drugs (formulary) for the other medical conditions the drug is approved to treat.

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 one month 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  exception .

Step therapy

Step therapy is a type of prior authorization . In most cases, you must first try a certain, less expensive drug on the plan’s formulary   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 exception.

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 Part B (Medical Insurance), 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 hospital outpatient setting , like an emergency department or during observation services, aren't covered by Medicare Part B (Medical Insurance) . 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.