What is Prior Authorization?
For certain medications, prior authorization may be required by some Medicare Prescription Drug Plans. This means that before coverage is authorized, the individual's doctor or prescriber must deem the medication medically necessary. It's also there to make sure medication is prescribed and taken correctly.
What is Step Therapy?
Step Therapy is a type of prior authorization. Typically, an individual's plan requires the patient to try the cheaper, generic, and proven-effective alternative on the formulary (drug list) before they 'Step up' to more expensive, brand-name medication. The generic drugs are considered 'Step 1' drugs while the brand-names are 'Step 2' drugs. The formulary may change at any time and the patient will receive notice as necessary. Prescribers may request an exception if it is deemed medically necessary for an individual to be prescribed the more expensive medication. Following an approval, the plan will cover the Step 2 medication.
What is Quantity Limit?
With both cost and safety in mind, plans may set quantity limits on medications covered over a certain period of time. This means for example, if an individual is prescribed two tablets a day or 60 tablets a month but their plan has a quantity limit of 30 tablets per month, the doctor or prescriber would need to obtain authorization from the Medicare Prescription Drug Plan for an increase in quantity.