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Prior Authorization

Plans may have drugs that require prior authorization. Prior authorization means before the plan will cover a particular drug, your doctor must first show the plan that there is a medically-necessary reason why you must use that particular drug. Plans do this to be sure these drugs are used correctly and only when medically necessary. Contact your plan about its prior authorization requirements before you talk with your doctor.


Step Therapy

Step therapy is a type of prior authorization. With step therapy, in most cases you must first try a certain less-expensive drug on the plan’s list that has been proven effective for most people with your condition, before you can move up a "step" to a more expensive drug. For instance, some plans may require you to try a generic drug (if available), then a less expensive brand-name drug that is on their drug list, before you can get a similar, more expensive brand-name drug covered.

Step 1 – Dr. Smith wants to prescribe an ACE inhibitor to treat Mr. Mason’s heart failure. There is more than one type of ACE inhibitor. Some of the drugs Dr. Smith considers prescribing are brand-name drugs covered by Mr. Mason’s Medicare drug plan. The plan rules require Mr. Mason to use the generic drug lisinopril first. For most people, lisinopril works as well as brand-name drugs.

Step 2 – If Mr. Mason takes lisinopril but has side effects or limited improvement, his doctor can provide that information to the plan to get approval to prescribe a brand-name drug. If approved, Mr. Mason’s Medicare drug plan will now cover this drug.

However, if you have already tried the similar, less-expensive drugs and they didn’t work, or if your doctor believes that because of your medical condition it is medically necessary for you to be on a more expensive step-therapy drug, he or she can contact the plan to request an exception. If your doctor’s request is approved, the step-therapy drug will be covered.



(Primary Source: Centers for Medicare and Medicaid Services - Your Guide to Medicare Prescription Drug Coverage 2008. This content may have been enhanced by Q1Group LLC to include further examples, explanations, and links.)


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