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What are some of the rules?

 To be sure certain drugs are prescribed and used correctly and only when truly necessary, plans may have certain standard rules, including:
  • Prior authorization--This means before the plan will cover these prescriptions, your doctor must contact the plan. Your doctor must show that the drug is Medically Necessary for it to be covered.
  • Quantity limits--This means how many pills you can get at a time.
  • Step therapy--This means one or more similar lower cost drugs must be tried before the step-therapy drug is covered (see example below).

Example of step therapy for a patient who needs a drug for heart failure
Step 1 --Dr. Smith wants to prescribe an ACE inhibitor to treat Mr. Mason's heart failure. There is more than one type of ACE inhibitor. Some of the drugs he considers prescribing are brand-name drugs in Mr. Mason's Medicare drug plan. The plan rules require Dr. Smith to prescribe the generic drug lisinopril first. For most people generic lisinopril works as well as brand-name drugs.

Step 2--If Mr. Mason takes lisinopril but has side effects or limited improvement, his doctor can prescribe a brand-name drug, like Prinivil® or Zestril® . Mr. Mason's Medicare drug plan will now cover this drug.




(Primary Source: Centers for Medicare and Medicaid Services - Medicare and You Handbook. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)


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  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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