A common feature of all insurance plans whether it's Medicare, a group or an individual policy is to regulate the prescription drugs prescribed for its members. This is done in four ways: requiring a prior authorization, step therapy, maximum dispensing limits or excluding certain medications from its prescription drug list.
Prior Authorization
Some drugs must undergo a criteria-based approval process by your insurance carrier prior to being covered under your health insurance plan. The approval process varies by insurance provider.
Step Therapy
Step therapy protocols require you to utilize medications commonly considered first-line medications prior to being able to using a medication considered second line or third line. You receive benefits for drugs subject to step therapy only after trying alternative medications first.
Prescription Drug List (PDL)
Your insurance carrier creates a prescription drug list (PDL) each year which dictates which medications are or are not covered by your insurance plan. The list can also change during the year depending on your policy guidelines.
Maximum Dispensing Limits
Maximum dispensing limits are based on the product information approved by the Federal Drug Administration (FDA) and recommendations from the drug's manufacturer. Your carrier limits the quantity of medication you are able to receive from your pharmacy at one time.
Restrictions
According to Humana, a health insurance company, the cost of a drug drops in price between 30 percent to 80 percent once the patent expires and it is available as in a generic form. Step therapy, prior authorization and PDL are ways to help control health care costs with maximum dispensing limits in place as a safety measure.
Considerations
You may not like the measures implemented by your insurance company to restrict dispensing specific medications; you can however get an exception made to each of the restrictions. The procedure for doing this will vary depending on your insurance carrier.
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