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Important Part D Terms

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Medicare Part D, for the most part, is pretty straight forward. It covers your medications for a stated copay or coinsurance amount. There are some terms that you may encounter with certain prescriptions and with drug plans in general. Below I outline some terms that will apply to all Medicare Prescription Drug plans. 

prior authorization

Plans may require a “prior authorization” to make sure certain prescription drugs are used correctly and used only when medically necessary. This is generally used when a medication is really expensive and they want to ensure no other treatments are available. Another reason is when a medication has extreme side effects and they want to be sure that you can handle them. 

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Your plan may require you to first try a generic prescription drug (if available), then a less expensive brand-name prescription drug on its formulary before it will cover a similar, more expensive brand-name prescription drug. Basically, they would like you to try a cheaper (generic) version of a medication first before you take the brand-name. If the generic works with in a month or two then everybody wins. If not then they will move you up to the brand-name drug. 

quantity limits

For safety and cost reasons, plans may limit the amount of prescription drugs. You will often see quantity limits on medications that are potentially addictive. A physician will only be able to prescribe a limited number of pills a month. They will have to request for approval and show reasons why a higher limit is needed if they believe more are necessary. 

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Every Prescription Drug Plan has its own list of covered drugs. This list is called a “formulary.” This list will tell you what medications are covered, how much you’ll pay, and if there are any special rules for any particular drug. Your plan’s formulary may also change annually. If this happens, you will get a notice from your plan provider. 

If you have any questions or concerns in dealing with these terms please feel free to contact us for support and answers. Generally, your physician will manage each of these situations for you. Yet, if there happens to be a time where they encounter issues, we can support their office in finding solutions.

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