Safety checks, drug management programs, and Medication Therapy Management

Safety checks

Before the pharmacy fills any prescription, your Medicare drug plan and pharmacist do routine safety checks, like checking for incorrect dosages or interactions with other medications you take. 

When you're prescribed opioids, your drug plan and pharmacy may do more checks to keep you safe, like:

• Checking for possible unsafe amounts of opioid pain medications
• Limiting your first opioid prescription to a 7-day supply or less
• Checking the use of opioids at the same time as benzodiazepines (commonly used for anxiety and sleep)

Opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help with certain types of pain but have serious health risks like dependence, overdose, and death. These risks can increase when you take opioids with certain other drugs, like benzodiazepines, anti-seizure medications, gabapentin, muscle relaxers, certain antidepressants, and drugs for sleeping problems. Check with your doctor or pharmacist if you have questions about your potential risk factors for an Opioid Use Disorder.

If your pharmacy can’t fill your prescription as written, they'll give you a notice that explains how you or your doctor can ask your plan for a coverage decision, including an exception to a plan coverage rule. An exception is when a drug plan decides to cover a drug that's not on its drug list, or to waive a coverage rule. You or your prescriber must ask for an exception and provide a statement explaining the medical reason why the exception should be approved. Follow the Level 1 appeals process to ask for an exception to a plan coverage rule.

You can also ask your plan for a decision before you go to the pharmacy, so you’ll know ahead of time if your plan will cover your prescription. 

Drug management programs

Medicare drug plans have drug management programs to help you use opioids and benzodiazepines safely. If you get opioid prescriptions from multiple doctors or pharmacies, or if you had a recent overdose from opioids, your plan may check with your doctor(s) to make sure you need this prescription and that you’re using it safely.

If your plan decides your use of prescription opioids and benzodiazepines may be unsafe, the plan may limit your coverage of these prescriptions under its drug management program. Your plan will send you a letter before it places you in its drug management program. You'll be able to tell your plan which specific doctor or pharmacy you prefer to get your opioids and benzodiazepines from, and give any other information you think is important for the plan to know. Your plan will send you another letter with its decision.

You and your doctor have the right to appeal if you disagree with the plan’s decision. The letter from your plan will tell you how to contact the plan if you have questions or want to appeal.

 Important tips if you're prescribed opioids

• Opioid medications can be an important part of pain management, but they can also have serious health risks if misused.
• Never take more opioids than prescribed. Also, talk with your doctor about any other pain medicines (prescription and non-prescription) you’re taking to make sure they don’t interact with opioids or cause serious side effects.
• Safely store and dispose of unused prescription opioids through your community drug take-back program or your pharmacy mail-back program.
• Talk with your provider about:
  • Your potential risk factors for an Opioid Use Disorder (OUD). Make sure to tell your doctor if you or your family have a history of substance use disorder or other issues that could make opioid use potentially unsafe.
  • Your opioid dosage and the length of time you’ll be taking them. You and your doctor may decide later you don’t need to take all of your prescription.
  • Having naloxone or nalmefene at home. Naloxone and nalmefene are drugs Medicare covers that your doctor may prescribe as a safety measure to rapidly reverse the effects of an opioid overdose.
  • Evaluating your pain level and setting goals for your pain and daily function.
  • Other options that Medicare covers to treat your pain, like non-opioid medications, physical and occupational therapy, acupuncture for lower back pain, individual and group psychotherapy, chiropractic services, and chronic pain management and treatment services.

Anyone taking opioids can develop an Opioid Use Disorder (OUD). Medicare covers treatment for OUD for as long as it’s reasonable and necessary.

Medication Therapy Management 

Plans with Medicare drug coverage   must offer Medication Therapy Management services to help people who meet certain requirements or are in a drug management program. If you qualify, you can get these services at no cost to you. These services usually include a discussion with a pharmacist or health care provider to review your medications and will help you manage your medications and take them safely.

Through Medication Therapy Management, you may get:

• A comprehensive review of your medications and the reasons why you take them
• A written summary of your medication review with your doctor or pharmacist
• A “Recommended To-Do List” and “Medication List” to help you make the best use of your medications (with space for you to take notes or write down any follow-up questions)

If you take drugs for more than one chronic health condition, contact your drug plan for specific details and to find out if you're eligible for a Medication Therapy Management program.