Sometimes, when visiting the pharmacy to pick up prescribed medicine, the full amount recommended by the doctor might not be received. This can happen because of something called quantity limits. These are rules set up by insurance companies and regulatory agencies to control how much of a certain medication is given out at a specific time. The goal of quantity limits is to make sure that prescription drugs, especially those that could be misused or cause an overdose (like controlled substances), are used properly and safely.
Quantity limits for prescription drugs can be frustrating for patients who need to manage their health. But these limits are there for safety reasons and to prevent the misuse of drugs. These limits are set using advice from the Food and Drug Administration (FDA) and the drug makers’ suggestions. In some situations, doctors may have to talk with insurance companies to get permission for higher amounts of certain drugs.
Read on to learn more about quantity limits and their potential impact on treatment.
What do quantity limits mean for prescriptions?
Quantity limits refer to the highest amount of a prescription drug that an insurance plan will cover over a specific period of time. These limits are set by insurance companies or pharmacy benefit managers (PBMs) to make sure medications are dosed correctly, reduce costs, and reduce the risk of overuse or potential side effects.
For example, if a doctor prescribes a medication for 30 days, but the insurance has a quantity limit of 15 days for that medication, the insurance will only pay for a 15-day supply of pills. One would need to pay out-of-pocket for the remaining supply.
The idea behind quantity limits is keeping patients safe and ensuring drugs are used correctly. Limits may prevent people from using too much medicine and ensure they follow the right dose. It may also prevent the misuse of drugs and oversupply, which could lead to wasting medicine or causing harm. The rules for quantity limits can change depending on location or specific insurance plan.
Which insurance plans use quantity limits?
Commercial health plans, such as those offered by private insurance companies, often have quantity limits that depend on the type of medication, local laws, and the insurance company’s own policies. Similarly, Medicare plans and Medicare Advantage plans also enforce quantity limits. In addition, state-funded health insurance programs like Medicaid, as well as the Department of Veterans Affairs (VA) health plans, may also have quantity limits to manage prescription drug usage and costs.
Quantity limits can change anytime, even between refills of the same medication. This is due to factors such as updates to healthcare guidelines and changes in drug formularies. It may be necessary to keep an eye on the insurance plan regularly to stay informed about any changes to prescription drug coverage, including quantity limits.
There are other ways insurance companies manage drug benefits, too. These include prior authorization and step therapy. Prior authorization means approval from the insurance company is required before they cover a certain medication. Step therapy involves first trying a cheaper or less recommended drug before moving on to a more costly or less recommended one.
What medications have quantity limits?
Quantity limits apply to various medications, and they may even depend on the formulation of a drug. Quantity limits don’t only apply to controlled substances. They can also be imposed on other prescription medications, including brand-name drugs, inhalers, or even over-the-counter (OTC) medications available by prescription.
Examples of medications that may need quantity limits include, but are not limited to:
- Proair HFA (albuterol)
- Pulmicort (budesonide)
- Spiriva (tiotropium)
- Vicodin (hydrocodone)
- OxyContin (oxycodone)
- Duragesic (fentanyl)
- Ultram (tramadol)
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Wellbutrin (bupropion)
Certain nasal sprays
- Nayzilam (midazolam)
- Valtoco (diazepam)
- Nasonex (mometasone)
- Varenicline (generic Chantix)
- Zyban (bupropion)
- Cialis (tadalafil)
- Viagra (sildenafil)
- Levitra (vardenafil)
- Copaxone (glatiramer acetate)
- Tecfidera (dimethyl fumarate)
- Emend (aprepitant)
- Entresto (sacubitril/valsartan)
- Rozerem (ramelteon)
- Tamiflu (oseltamivir)
- Zomig (zolmitriptan)
Quantity limits may come in various forms, such as a one-per-day limit or monthly time frames. These rules can also include a cap on the number of pills allowed. For instance, one might have to wait until a predetermined amount of time has passed before obtaining a refill.
What to do if your prescription has quantity limits
If the prescribed medication has quantity limits set by insurance companies, don’t worry. There are several steps that can be taken to make sure the medication is received.
First, request an emergency prescription refill. Contact the pharmacy and explain the situation; they may provide a temporary refill until the problem can be resolved.
Another option is to consult the prescriber. They may override the quantity limits by contacting the insurance company or submitting a medical necessity form. Keep in mind that healthcare providers may need to provide evidence that a higher dose or quantity is necessary for treating the medical condition.
If an exception request gets denied, there are still options. It would help to discuss any alternative treatments with a prescriber, which may not have quantity limits or may better align with insurance coverage. Exploring government assistance programs that may help cover the costs of medications is also an option.
Here are some tips for pharmacy customers who face quantity limit restrictions:
- Be proactive and communicate clearly with the prescriber and pharmacist with any concerns.
- Research the insurance plan’s coverage rules on medications and discuss them with the prescriber.
- Always keep track of medication usage and refill requests to avoid running out due to quantity limits.
- Consider using SingleCare to save on medications not covered by insurance or those that have quantity limits.
By following these steps and staying up-to-date, one can be better prepared to handle the challenges that come with prescription quantity limits. This will help ensure that access to the treatment needed is accessible.