What is prior authorization, step therapy, and quantity limit?

What is prior authorization, step therapy, and quantity limit?

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.

Medicare True-Cost Revealer. Now you can see the real costs of each Medicare plan... before you buy it.

Helpful Hint

Find out what every Medicare plan really costs

Each Medicare plan covers different drugs, and re-imburses different amounts.

Until now, it was impossible to compare Medicare plans — to know how much you will really pay under each plan.

Medicare Helper is proud to introduce our Medicare True-Cost Revealer. Just tell us your drugs, and we’ll show you the "Everything Cost" for each plan — that is, the real cost of the plan through the year.

Amazing. And completely free.

Try Medicare True-Cost Revealer

What is prior authorization, step therapy, and quantity limit?