Get all the facts on restrictions

KNIGHT RIDDER NEWSPAPERS
Q. My aunt received her Medicare drug card, but the pharmacist told her she would have to get her doctor to fill out a form before the plan would cover her prescription.
Does this mean her medication isn't covered by the plan? -- Louis
A. If your aunt needs her physician to fill out a form to get her prescription covered by her plan, either the drug is not covered by her Medicare drug plan, or the plan covers the drug but places a restriction on its use.
Either way, your aunt will probably need help from her doctor to be sure she gets the medication she needs.
Your aunt may want to start by asking her pharmacist to find out if the prescription is covered by her Medicare drug plan.
If the plan does not cover the medication, your aunt might ask her doctor to prescribe a similar drug that is covered by her plan.
Alternatively, she might want to work with her physician to appeal the plan's decision.
Otherwise, she could end up paying the full cost of the prescription that is not covered.
If the drug is covered by her plan, but subject to restrictions, her physician needs to fill out a form that explains why she needs that specific medication.
There are three types of restrictions that are commonly used by Medicare drug plans: quantity limits, which restrict the amount of a drug an enrollee can get (for example, the number of pills per month); step therapy rules, which require an enrollee to try a less expensive drug before getting one that is more expensive; and prior authorization, which requires the enrollee's doctor to explain why the patient requires a drug before the plan will cover it. There is no guarantee the plan will cover the drug, even after getting an explanation from your doctor.
It would be a good idea for your aunt to talk to her pharmacist and physician to understand more about what she needs to do to get her prescriptions filled.
This column was prepared by the Kaiser Family Foundation, an independent, nonprofit private foundation based in Menlo Park, Calif., not affiliated with the Kaiser Permanente health plan. Send questions about the new Medicare drug benefit to Medicare Q & amp; A, The Kaiser Family Foundation, 1330 G St., NW, Washington, DC 20005 or MedicareQ@kff.org.