Plans have rules that limit how and when they cover certain drugs. These rules are called requirements or limitations. You need to follow the rules to avoid paying the full cost of the drug out-of-pocket. If needed, you and your doctor can also ask the plan for an exception.
Here are the requirements and limitations you may see on a drug list:
PA – Prior Authorization
The plan needs more information from your doctor about how the drug is going to be used before it will pay.
QL – Quantity Limits
The plan will cover only a certain amount of a drug or type of drug for one copay or over a certain number of days.
ST – Step Therapy
The plan wants you to try one or more lower-cost alternative drugs before it will cover the drug that costs more.
B/D – Medicare Part B or Medicare Part D Coverage Determination
Some drugs can be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). The plan needs more information about how a drug will be used to make sure it’s covered by the right part of Medicare.