Make sure your prescriptions are on the formulary, and be aware of any possible restrictions.
By STEPHEN NOHLGREN, Times Staff Writer
Published December 4, 2005
Price is not the only consideration for picking a Part D drug plan. Plans also vary widely on how readily they approve your particular prescriptions.
Some plans may not include your prescription on their formulary at all. Others may cover your drug in theory, but impose restrictions that require your doctor to fill out so much paperwork that you may not actually get that drug.
Restrictions come in three forms.
PRIOR AUTHORIZATION: Where your doctor must justify the prescription in writing and the drug plan must approve it.
QUANTITY LIMITS: This might be as simple as limiting your intake to one pill a day, when that is how the manufacturer intended the pill to be taken. Or it might be more restrictive - like one plan's 60-day limit on Nexium or another plan's limit of one inhaler a month, even if your doctor wants you to use two.
STEP THERAPY: Where the plan requires you to try a similar drug first, without success, before your doctor can prescribe your particular medication.
Some plans "make it look like their formularies are very broad. All the drugs are covered," says Dr. Thomas Clark of the American Society of Consultant Pharmacists. "But when you drill down to the next level, it turns out to be extremely difficult to get the drugs paid for. You have to get physicians to fill out forms and jump through hoops to get coverage. Doctors aren't going to have the time to do that."
Medicare's Web site, www.medicare.gov lists drug plans and the types of restrictions they impose on different drugs. You get the list by entering your medications on the "Formulary Finder" option on the home page.
As a random test, the St. Petersburg Times took 10 common drugs and ran them through the Formulary Finder to see how different plans imposed restrictions on 30-day supplies. Only the two Blue Cross Blue Shield BlueScript plans covered all 10 drugs on their formularies without imposing any restrictions. This ease of access is one reason the BlueScript plans are rarely the cheapest when people compare plans by cost.
One plan, AmeriHealth Advantage, did not impose any restrictions, but it also covered only three of the 10 drugs on its formulary.
The accompanying chart lists the types and number of restrictions each plan imposed on the sample drugs. The AARP plan, for example, required no prior authorizations, but had quantity limits on all 10 drugs. It also required step therapy on Albuterol.
This chart is a broad indication of how plans impose restrictions. Medicare does not have any detailed information on what each restriction might entail. To get that information, you would have to contact the drug plans individually.
The drugs used in the test were: Albuterol aerosol, Aricept, Avandia, Cozaar, Detrol LA, Fosamax, Lipitor, Lovastatin, Nexium and Lunesta.
