Safety checks, drug management programs, and Medication Therapy Management

Safety checks

Before the pharmacy fills your prescriptions, your plan and pharmacy perform 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.
• Limiting use of opioids at the same time as benzodiazepines (commonly used for anxiety and sleep).

Opioid pain medicine can help with certain types of pain but has risks and side effects (like addiction, overdose, and death). These risks 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 contact your plan to ask for a coverage decision, including an exception to a plan coverage rule. An exception is when a drug plan decides to cover a drug that's not on its drug list, or to waive a coverage rule. You or your prescriber must request an exception, and your doctor or other prescriber must provide a supporting statement explaining the medical reason for the exception.

You can 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 drug management programs to help people use opioids and benzodiazepines safely. If you get opioid prescriptions from multiple doctors or pharmacies, or if you had a recent overdose from opioids, your plan may check 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 will send you a letter before it places you in its drug management program. You'll be able to tell your plan which specific doctor or pharmacy you prefer to get your prescription opioids and benzodiazepines from, and give any other information you think is important for the plan to know. Your plan will send you another letter with its decision.

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

 Important tips if you're prescribed opioids

• Opioid medications can be an important part of pain management, but they can also have serious health risks if misused.
• Never take more opioids than prescribed. Also, talk with your doctor about any other pain medicines (prescription and non-prescription) you’re taking.
• Safely store and dispose of unused prescription opioids through your community drug take-back program or your pharmacy mail-back program. 
• Talk with your provider about: 
  • Having 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.
  • 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.
  • 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. 

Medication Therapy Management 

Plans with Medicare drug coverage   must offer Medication Therapy Management services to help people who meet certain requirements or are in a drug management program. If you qualify, you can get these services at no cost to you. These services usually include a discussion with a pharmacist or health care provider to review your medications and will help you manage your medications and take them safely.

Through Medication Therapy Management, you may get:

• A comprehensive review of your medications and the reasons why you take them
• A written summary of your medication review with your doctor or pharmacist 
• A “Recommended To-Do List” and “Medication List” to help you make the best use of your medications (with space for you to take notes or write down any follow-up questions)

If you take drugs for more than one chronic health condition, contact your drug plan for specific details and to find out if you're eligible for a Medication Therapy Management program.