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.
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.