Prior Authorization (PA)
Prior authorization means that you will need prior approval from an insurance plan before you fill the prescription. If a drug has prior authorization, you will need to work with the plan and the doctor to get an exception. Call the insurance company or visit their website to learn more about specific prior authorization requirements.
Quantity Limit (QL):
For safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time. If the drug has a quantity limit restriction, you should contact the plan for more details. If the patient takes one pill per day and the drug has a 30 day/month quantity limit, the impact will be minimal (i.e.,they may not be able to refill the prescription until a few days before running out of pills). If the patient currently takes 2 pills per day and the quantity limit is 30 pills per month, you would need to work with the plan to get authorization for the higher quantity.
Step Therapy (ST):
In some cases, plans require a patient to first try one drug to treat their medical condition before they will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A doesn't work for the patient, then the plan will cover Drug B. If a drug has step therapy restrictions, you will need to work with the plan and your doctor to get an exception.
Not Covered (NC):
Not every medication is covered on a plan's formulary. When a drug is "Not Covered" by a plan, the enrollee receives no coverage benefits for that medication. This means the patient will pay full cost (as determined by the pharmacy) for this medication. Since the medications are not covered, they do not count toward Coverage Phase thresholds. Amplicare displays an estimated full cost in this situation. Sometimes patients get an exception to receive coverage anyway. Many pharmacists and patients use Amplicare to consider Therapeutic Alternatives with formulary coverage.
Day supply Limit 60 (DSR60) / Day supply Limit 90 (DSR90):
This plan does not cover either a 60 or 90 day supply of the medication. It is possible for a plan to have both a Days Supply Restriction for 60 days and for 90 days. Consider filling 30 day prescriptions for this medication.
A more specific example: if a plan has a day supply restriction of 60 days for a medication ("DSR60"), they will cover that medication if the day supply is under 35 days and/or 84-90 day supplies, but not days supplies between 35-83 (in most cases).
Now that you understand certain plan restrictions familiarize yourself with Amplicare's internal plan tags.