What types of restrictions are placed on drugs? - Community Health Plan of Washington - Medicare Advantage

What types of restrictions are placed on drugs?

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs. These types of restrictions include:

Prior Authorization (PA): For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide the appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

Step Therapy (ST): This requirement encourages you to try a less costly but just as effective drug before the plan will cover another drug. For example, if Drug A and Drug B treat the same medical condition and Drug A is less costly, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

Quantity Limit (QL): For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

B versus D Determination (BVD): This is simply a coverage determination to see which part of Medicare will cover your drug. There are certain criteria that some drugs must meet to be covered under Part D. (For example, chemotherapy and the drugs prescribed along with it to treat nausea and vomiting are subject to a B vs D determination).

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