Did you go to the pharmacy recently and the person at the counter said, “I can only give you 10 pills” or “you can’t have this medication until you try another one first” or “I have some concerns about this medication based on other medications you are taking.”
Many of our clients ask us questions about the issues noted above related to prescription drug coverage. We hear everything from, “I am glad they do this” to “why are they hassling me?” Given the concerns expressed by our clients, we thought we would try to shed some light on the medication management programs used by the pharmacy benefit plans in order to keep your prescriptions safe and affordable. I realize to some, these programs can seem like a hassle, but for the most part, they are intended to keep patients safe and maintain prescription drug affordability for Medicare Beneficiaries.
First, the plans use a program called “Quantity Limits.” You may see the letters QL in your formulary if you have a copy of your plans’ drug formulary. (If you would like a copy, call your plan and request a hard copy of the formulary, they must provide a copy). Quantity limits are just what the term implies. For certain medications, especially medications like opioids, a physician, and the plan, can only provide a small amount of the medication in one prescription. For obvious reasons, this is done to protect the patient form potentially harmful doses of a medication. In other circumstances, the medication may be very expensive and to avoid waste and additional cost to the beneficiary, the medication is limited in quantity until the impact can be evaluated. As always, check with your physician and your plan to find out if your medication is subject to quantity.
A second control mechanism is call “Step Therapy.” Step therapy, noted as ST in your formulary, requires that you use a less expensive medication before you begin to use a more expensive medication to treat your condition. This happens so that providers use a less costly approach to treating a patient starting with a medication that will cost the Beneficiary less money. In some cases, if you and your physician decide that a more costly medication must be used for treatment, you can appeal the step therapy program with your plan. Again, please check with your physician to understand the issues and make the best decision for you and your treatment.
Another safety program performed routinely by your pharmacist or Medicare drug plan is something called “safety alerts.” Under this program, there is a check to see whether the medication is accurate, a check for drug interactions with other medications and a check to make sure that the dosing is safe. These reviews will always occur when an opioid medication is prescribed. If the pharmacy cannot fill the prescription as written, the pharmacist will provide a notice of how you or your doctor can call or write your health plan and ask for an appeal of the decision. Please, please speak with your physician about the impact and length of time when taking an opioid medication. These medications are powerful, and it is very important that you understand the impact to you before you take the medication. Also, if you are being prescribed medications by multiple physicians, please let each physician know what you are taking so they can consider the impact on you related to the other medications.
Once again, these programs are designed with for your safety so I hope you view them in this manor rather than as a hassle. Please let us know if you have any questions on your prescription drug benefits or on any other part of your Medicare benefit plan. We are always here to assist you and we can be contacted at: firstname.lastname@example.org or at 717-980-3201.
Have a wonderful February everyone!
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