Medicare Part D plans can change formulary or drug list designs each year and your Medicare prescription drug plan may have implemented
utilization management (or drug usage management) restrictions in their formulary to keep
costs down and protect their plan members.
Utilization management
includes such prescription controls as
Quantity
Limits (for example, only allowing plan members 30 tablets per 30 days) or
Prior
Authorization (requiring members to get plan approval before filling a
prescription) or
Step
Therapy (having members try lower-costing medications before using a more
expensive drug).
Utilization management restrictions can be applied to formulary drugs provided by stand-alone Medicare Part D plans (
PDPs) or Medicare Advantage plans that include prescription drug coverage (
MAPDs)
If your prescription drug is no longer
covered due to a newly imposed usage or utilization management restriction,
you can ask your Medicare prescription drug plan for a one-time 30-day
transition or temporary supply while you and your prescribing physician work to
satisfy the usage management requirement or find another formulary drug. You can click here to read more about
transition fills.
Please remember, you always have the right to ask
your plan for a formulary exception if you wish to
be exempted from a specific usage management requirement.
Click
here to learn how to request a formulary exception.
If the restriction is
added mid plan-year, you may not be subject to the restriction.
Reminder: Both our
Formulary
Browser (showing all drugs for a single Medicare plan) and our
Q1Rx® Drug
Finder (Q1Rx.com - showing all Medicare plans covering a single drug) display the
details of the drug utilization management requirements along with the drug
cost-sharing information for all Medicare Part D plans and Medicare Advantage
plans.