Prescription Drug Plan Restrictions

“I can’t get no satisfaction”- What to do about Prescription Drug Plan restrictions.

Coverage Restrictions
Step Therapy with Medicare Part D
As the Rolling Stones once said, “you can’t always get what you want…”

At times this can also the case for your Medicare Part D prescription drug plan. Some plans have special restrictions for specific drugs included in your plan’s coverage. For example, say Mick Jagger has a stand-alone prescription drug plan. (We’re keeping with the Rolling Stones theme for this post, he is of Medicare age after all even if he is English). Mick goes to the doctor and is prescribed 60 pills a month of blood pressure medication, but his plan only covers 30 pills a month. Mick has expirienced a quantity limit for this prescription drug. Other restrictions come in the form of step therapy. Step therapy is when a plan requires you to ease your way into a prescription medicine by first using a less-powerful, more inexpensive version of the drug.


There are ways out of prescription drug plan restrictions.

Each plan should have an appeals process, which should generally follow the same protocol. First, your doctor must get involved. Ask him/her to send a letter to your drug plan asking to take the restriction away. The reasoning for the request could be that this is the only drug sufficient for your condition or that the prescribed dose is essential to your health.

If your plan denies your request, you can meet with your doctor again and send a follow up letter specifically addressing the plans reasons for the rejection. If your is still saying no, you and your doctor plan can write to MAXIMUS Federal Service to ask that the restriction not apply to you. This independent group handles the appeals process from here and is a separate entity from your prescription drug plan company MAXIMUS is the independent group that considers Parts C and D appeals. MAXIMUS is not connected to your plan and makes an independent decision.

To get more information about Medicare Supplement Insurance planstalk to one of our Medigap plan representatives today or get a free quote today.

One thought on “Prescription Drug Plan Restrictions

Leave a Reply

Your email address will not be published. Required fields are marked *