Prescription Drug Coverage – Step Limits, Quantity Limits, and Prior Authorization

Last Updated : 04/04/20193 min read

If you’re covered under a Medicare Advantage plan with prescription drug coverage or a stand-alone Medicare Part D Prescription Drug Plan, you may have to follow certain guidelines when you access your benefits. For example, you may be required to use a network pharmacy and if you don’t, you may pay higher copayments for certain types of medications.

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In all cases, your plan’s prescription drug coverage is based on a formulary, or list of approved medications and the benefits available for each. A formulary may change its coverage at any time, but the insurance company must inform you in writing when the changes occur.

Some plans with Part D prescription drug coverage use additional cost control measures to keep expenses down. These measures may include, step limits, quantity limits, or prior authorization. If your plan uses these measures, here’s what you should know about how they work with your prescription drug coverage.

What is step therapy?

Sometimes, there are several different medications available to treat your condition that provide the same benefits; some are less expensive than others. Because it is in the best interests of both you and your health plan to keep prescription drug coverage costs low, your plan may tell your health-care provider to try you on the least expensive option to see how you respond before approving payment for a more expensive one.

What are quantity limits?

Your prescription drug coverage may include quantity limits for certain medications. This usually happens in one of two ways:

  • You may only be able to get a certain number of doses or pills in a specific time period, usually 30 days; your plan will not pay for refills that exceed the limit.
  • Your doctor may only be able to prescribe a certain number of doses to treat your condition; your plan won’t pay for this medication beyond that particular quantity limit.

What is prior authorization?

Prior authorization simply means that your health-care provider must contact your plan to get permission before filling the prescription for a certain medication. At times the plan will want proof that a certain medication is medically necessary before it covers that medication.

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What if I want to appeal my plan’s prescription drug coverage decision?

Under the Medicare program, you have certain rights and protections, one of which includes the right to request a review of any prescription drug coverage decision made by your plan. Either you or your health-care provider can request a review from your plan or an exception to your plan’s formulary. If you are unhappy with the outcome, you or your authorized personal representative can initiate a formal appeal from Medicare. This page explains the prescription drug coverage appeals process in more detail.

Do you have questions about prescription drug coverage under the Medicare program? I’m available to help you any way I can. To get information via email, or to schedule a phone call at your convenience, use one of the links below. You can view a list of plans in your area by clicking the “Compare Plans” button.

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