Q: I've read that my drug plan can put restrictions on my drugs. What does that mean?

A: Drug plans will sometimes put restrictions on certain drugs they cover. Stand-alone drug plans that supplement Original Medicare, and the drug coverage that comes with Medicare Advantage plans, both have coverage restrictions. These restrictions can include prior authorization, quantity limits, and step therapy.

Prior authorization means that your doctor must get special approval from your plan in order for that prescription to be covered. It is also sometimes called "preauthorization" or "preapproval" by your plan.

Quantity limits occur when your plan will only cover a certain amount of a prescription drug. For example, your plan may only cover 30 pills for a particular drug every month, even though your doctor has prescribed 60 pills a month.

Step therapy is when your plan requires you to try another, less expensive, drug first to see whether it will be effective before your plan approves the drug for which your doctor wrote the prescription.

You have the right to appeal any restrictions that a plan puts on a drug. The steps of an appeal are the same for all Part D plans:

1. The first thing is to have your doctor write to your drug plan, asking that the restriction on the drug be removed for you. This letter should inform the plan that other drugs on the formulary would not work as well for you, that other drugs could be harmful, or that there are medical reasons for the prescribed dose. This process of sending a letter with reasons to remove the restrictions is called requesting an exception.
   
2. If the plan denies the exception request, you and your doctor may write back to ask your plan for a redetermination. It is best if this response includes a statement from your doctor that responds specifically to your plan's reasons for denying the exception.
   
3. If your plan denies the redetermination, you and your doctor may write to MAXIMUS Federal Services to ask that the restriction not apply to you. MAXIMUS is the independent group that considers Part C and Part D appeals. MAXIMUS is not connected to your plan, and makes an independent decision. There are higher levels of Part D appeal after MAXIMUS, but most cases are decided by the time they get to the MAXIMUS level.

Before appealing, talk to your doctor about whether you can change your prescription to a drug that would be equally effective but does not have the same restrictions.

Source: Centers for Medicare and Medicaid Services