Restrictions on Part D Drug Coverage

What happens if any of my drugs is restricted?

You’ll need to talk to your doctor about it. It could be that an equivalent drug on the plan’s formulary that isn’t restricted—a generic, for example—would work just as well for you. And in that case, you’d save money by paying a lower copay, as well as saving yourself some hassle.

Otherwise, your doctor would have to ask the plan for an exception to its rules and show why you need the prescribed medication or dosage for your health. If the plan agrees, it covers the drug. If it turns down the request, you have the right to appeal the decision. Note, however, that you and your doctor can request an exception only after you’re enrolled in a plan, not before you join it.

Must I go through this process every year if I stay in the same plan?

It depends on the plan’s policy. Some plans allow you to carry over coverage granted through an exception from one year to the next. Some require you to request an exception for the same drug annually—or even, in some circumstances, more frequently. If the plan’s policy isn’t clearly explained in its enrollment materials or on its website, call its customer service number to find out.

What if I want to switch to another plan for next year?

If you’ve been granted one or more exceptions by your current plan, and are considering switching to another, one of the factors in your decision to switch should be whether or not the new plan places any restriction on the same drugs.

In the case of a medication you’re already taking, the law allows you the right to coverage for the first 30 days in a new plan (or 90 days if you move into a nursing home), regardless of whether the plan places restrictions on this drug or doesn’t even normally cover it at all. This grace period gives you time to take steps, with your doctor’s help, to change to an alternative drug or to request an exception.

Patricia Barry is a senior editor with the AARP Bulletin.