What does it mean if my Prescription Drug has a Limitation?

When an insurance company provides coverage for a certain medication, it may impose conditions or limitations on the coverage. “Cost utilization measures” refers to a term used to describe these prescription medication limitations. Individual prescriptions, rather than the entire formulary of the insurance plan, are usually subject to prescription drug restrictions.

The following identify the three main categories of drug limits:

• Quantity Limits
• Prior Authorization
• Step Therapy

Quality Limits

Taking too much medicine or taking it too frequently might aggravate your health and cause you to see specialists, buy more medicine, and therefore, raise your healthcare bills. Because of this, private health insurance companies that provide prescription medicine coverage may impose quantity restrictions. When a covered drug has a quantity restriction, the plan will only pay for a certain amount of the medication for a certain amount of time. The plan may, for example, limit coverage of certain prescription medicine to 30 pills each 30-day period.

The insurance company will not pay your prescription medication costs if you attempt to refill a prescription many days before the 30-day period expires or if your doctor recommends a larger quantity than the maximum recommended. The total quantity of prescription drugs that a pharmacy can deliver at one time depends on the Insurance Health Plan. This sort of restriction is rarely a substantial impediment to patient access. These restrictions ensure that a patient does not obtain more medicine than is recommended by best practices or medical recommendations.

Prior Authorization

Prior authorization, also known as preauthorization or prior approval, requires a doctor or patient to first obtain permission from the health plan before being covered for a certain prescription medicine. Obtaining prior approval verifies that the prescription medicine falls under the category of “medically essential”. Also, the approval will confirm that the regime follows best practices and the medical criteria for treating the patient’s condition. For all or almost all high-cost specialty drugs, many plans demand prior permission. Some drugs cost more and have more adverse effects than others, while others may have time limits on how long the drug may be used. Some plans demand prior authorization to ensure that certain drugs are used properly.

This process requires a prescribing doctor or pharmacist to first obtain permission for a medication’s coverage. The pre-authorization procedure allows the prescribing physician and the plan’s clinical staff to share information on the health condition that the prescription medicine treats, as well as other drugs often used to treat the condition, if appropriate. If your insurance company needs prior permission for a certain drug and you do not obtain it before getting your prescription filled, the pharmacy will charge you for the full retail price of the medication.

Step Therapy

Step therapy refers to prescription drug restrictions in which less costly drugs must prove that they do not work for a beneficiary’s medical condition before a more expensive medication for the same ailment becomes covered. This program was created for those who need to take drugs on a regular basis. For example, drugs taken for high blood pressure and high cholesterol. Prescription medications are divided into two groups in Step therapy: front-line drugs and backup meds, according to their cost.

Patients must first take a lower-cost medicine for a period of time before getting coverage for a higher-cost prescription under step therapy. Because the patient and physician must establish that a lower-cost drug does not work before covering a higher-cost prescription, this practice refers to “fail first.” Step treatment does not generally refer to anti-cancer drugs at the moment, although it focuses on pain meds.

Front-line drugs are generic, low-cost medications that doctors initially prescribe.  These drugs usually deliver the same therapeutic advantages as the more expensive brand-name treatments. The formulary of the plan can vary from year to year, which means that a prescription medicine you use for one year may have one or more of these limits, but not the following. If a change impacts you, your plan will notify you. In addition, your plan will notify you of benefit changes in the autumn through a mailing that contains the plan’s Annual Notice of Changes and Evidence of Coverage paperwork.

Prescription Drug Utilization Management

Utilization management refers to a term used by health insurers to describe a set of treatments and cost-cutting measures. In its prescription drug benefit, health plans typically use usage control approaches, especially for high-cost specialty drugs. Because many cancer therapies are classified as specialty tiers, cancer patients may need to meet usage control standards prior to receiving drug prescriptions. Step treatment, prior authorization, quantity limitations, and mandated generic substitution are all common prescription drug use control methods.

Mandatory Generic Substitution

When a patient chooses a brand-name medicine over a generic counterpart, some health plans require the patient to pay the cost difference between the generic and brand-name drug in addition to the brand-name drug’s standard cost-sharing. When generic drugs are available, this usage management method aggressively encourages their use. Upon a plan adopting forced generic replacement, it usually does so across the board, not only for certain medications.