If a member requires more medication than the allowed quantity limit, what can they do?

When a member requires more medication than what is typically allowed under their plan's quantity limits, the appropriate course of action is to request an exception from the plan through their healthcare provider. This process is crucial because it allows the member to present their specific circumstances and medical needs to the insurance company. The healthcare provider can provide the necessary documentation and justification, which increases the chances of receiving approval for the additional medication.

Requests for exceptions are often established protocols in managed care plans, allowing for flexibility in unique situations where standard limits may not meet the patient’s health needs. This ensures that treatment can be safely and effectively tailored to the individual while still adhering to the guidelines of the insurance policy.

In contrast, simply contacting the pharmacy for advice may not resolve the issue, as the pharmacy operates under the guidelines set by the health plan and cannot override them. Automatically receiving the extra dosage without going through proper channels is not a standard practice, as quantity limits are in place for various reasons, including safety and cost management. Waiting until the next prescription period would not address the immediate need for additional medication and could potentially jeopardize the member's health.