How Does the Drug Management Programs Work Under Medicare?

A drug management program is a tool that Medicare Part D Prescription Drug Plan can use to limit at-risk beneficiaries’ access to certain drugs. Plans use clinical guidelines to identify beneficiaries who are at risk for misuse or abuse of frequently abused drugs, such as opioids.

At-risk beneficiaries may be required to use one provider and/or one pharmacy to get flagged medications. This is known as pharmacy/provider lock-in. If an at-risk beneficiary has Extra Help, an assistance program that helps with drug costs, they cannot use the Extra Help Special Enrollment Period (SEP) to make changes to their coverage. The Extra Help SEP allows most beneficiaries with Extra Help to change their coverage up to once per quarter for the first three quarters of the year. If a beneficiary is found to be at risk, their plan must send two notices.

  • The first notice declares the beneficiary potentially at risk. It includes:
    • The plan’s proposed coverage limitations (such as pharmacy lock-in)
    • Information on any limitation on the availability of the Extra Help SEP, if relevant to the beneficiary
    • Timeframe for the plan’s decision. The beneficiary has 30 days to submit relevant information to the plan. They also may submit pharmacy/prescriber preferences, in the case of a proposed lock-in
  • The second notice declares the beneficiary at risk and gives them the option to select provider and pharmacy preferences, as well as to appeal for redetermination.

Read More: What Are the Medicare Safety Reviews?
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