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What special rules or limits might I need to know?

Plans may have special rules or may set limits on how you can get your drugs. These rules encourage you to use drugs that cost the least. Three of the most common controls are:

  • Prior authorization
    Your Medicare Prescription Drug Plan may have to approve some drugs before your doctor writes the prescription. Otherwise, the plan will not pay for it. Your doctor’s office will help you do this.The Medicare Prescription Drug Plan does this to make sure:

    • The drug is a standard medical treatment for your condition and
    • Your doctor has considered other drugs that treat your condition effectively at a lower cost.
  • Quantity limits
    The plan may let you have only a certain amount of the drug each month. This is called a quantity limit. For example, the normal dose for a certain drug is one pill a day – or 30 pills a month. Some people might need two pills per day, or 60 pills per month.   The plan may limit the quantity for the month to 30 pills. Then the plan would only pay for 30 pills.

If you need more than the plan allows, you and your doctor would need to ask the plan for an exception. You would have to tell the plan why the lower amount doesn’t work for you. (For more information, see Exceptions to the Limits)

  •  Step therapy
    These are instructions that say what drugs to use for a condition. They start with the simplest (and usually cheapest) drug to treat the problem or condition. If that drug doesn’t work, then you go to the next level and try that one. If that doesn’t work, you try the next level.

Over-the-Counter Drugs (OTC)
Some drug plans that use step therapy may ask you to start with an over-the-counter medication—a drug you can buy without a prescription. If you have to use an over-the-counter drug first, the plan has to give you the over-the-counter drug for free. The plan cannot charge you for it.

NEXT: What if my drug is not on my plan’s drug list?

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