For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have restrictions that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.
You can find out if your drug has any restrictions by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list click here and enter your ZIP code. Choose one of the available plans in your area and view the plan details.
Restrictions on your drug apply to retail and mail service. These may include:
Please use the Farm Bureau Select Rx prescription drug list or the Farm Bureau Essential Rx prescription drug list to identify the drugs covered by Farm Bureau Health Plans Part D plans. Use this as a guide to help manage the overall cost of prescription drug benefits.
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES
You (and your doctor) can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.
- You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the co-payment or co-insurance amount we require you to pay for the drug.
- If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
- Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan’s Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
- Tier exceptions are not available for drugs in the Specialty Tier.
- Tier exceptions are not available for drugs in the Preferred Generic Tier.
- Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to the generic-only tier level.
- Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.
Generally, the plan will only approve your request for an exception if your doctor provides information that the alternative drugs included in the plan's formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.