What is Prior Authorization, Step Therapy and Quantity Limits?

Prior Authorization


When your doctor prescribes a medication, you trust it's the right one for you. That's not always the case. And that's why we have programs like prior authorization. When we review certain drugs before your plan covers them, it helps make sure you're getting the right medication for the right situation.
 

Why would a drug need prior authorization?

Here are some of the reasons we require prior authorization for a drug:

  • The drug has dangerous side effects or can be harmful when combined with other drugs.
  • The drug should be used only for certain health conditions.
  • The drug is often misused or abused.
  • There are less expensive drugs that might work better.
  • To determine whether the drug is covered by Medicare Part B or Part D
 

What if my prescription requires prior authorization?

First, you or your pharmacist should talk to your doctor. There may be another drug you can take that doesn't need prior authorization. If not, your doctor can start the approval process by calling our Pharmacy Help Desk at 1-844-838-0706.

You can also start the approval process yourself by filling out and sending in a coverage determination form.

 

How do I know if a prescription requires prior authorization?

You can use your plan's drug list, also called a formulary. Start by finding reading TakeCare’s Formulary here. Then look for a PA after the name of your prescription.

 

Step Therapy

 
Step therapy is a type of prior authorization. In most cases, you must first try a less expensive drug on the Medicare Prescription Drug Plan's formulary (also called a drug list) that has been proven effective for most people with your condition before you can move up a "step" to a more expensive drug. This might mean trying a similar, more affordable generic drug instead of a more expensive, brand-name medication. The more affordable drugs in the first phase are known as "Step 1" prescription drugs. Please note that the formulary may change at any time. You will receive notice when necessary.
 
However, if you have already tried the more affordable drug and it didn't work or if your prescriber believes that it is medically necessary for you to be on a more expensive drug, he or she can contact the plan to request an exception. If your prescriber's request is approved, the plan will cover the more expensive drug. The more expensive drugs are known as "Step 2" prescription drugs, and Medicare will not cover them until Step 1 drugs are first tried unless an exception is obtained.
View TakeCare’s Step Therapy
 

Quantity Limit

 
For safety and cost reasons, plans may set quantity limits on the amount of drugs they cover over a certain period of time. For example, a person may be prescribed a medication to take two tablets per day, or 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that medication, your doctor or prescriber will need to work with the Medicare Prescription Drug Plan to get authorization for a higher quantity.
View TakeCare’s Quantity Limits


 

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