Coverage restrictions, also known as utilization management tools, are rules that you have to follow before your plan will cover your drug. There are three main types of coverage restrictions: prior authorization, step therapy, and quantity limits.
- Prior authorization means that you must get approval from your Part D plan before the plan will pay for the drug. Your provider is often part of this process and can provide the documentation needed to prove that the medication is medically necessary.
- Step therapy means that your plan requires you to try a cheaper version of your drug before it will cover the more expensive one.
- Quantity limits restrict the quantity of a drug you can get per prescription fill, such as 30 pills of Drug X per month.
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