Question 1

What does prior authorization mean on a Medicare Part D drug?

Accepted Answer

Prior authorization means the plan will not pay for the drug until your prescriber submits clinical justification and the plan approves it. The prescription is not denied outright, but nothing is covered until the request is approved. Your prescriber has to submit it; you cannot file it yourself.

Question 2

What is step therapy in Medicare Part D?

Accepted Answer

Step therapy requires you to try one or more alternative drugs first, and to have them fail or cause problems, before the plan will cover the drug your prescriber chose. Some plans grandfather patients already stable on a therapy and some do not, which is worth checking before switching plans.

Question 3

How do I request a Medicare Part D coverage exception?

Accepted Answer

You request a coverage determination from the plan. The prescriber must supply a statement explaining why the preferred alternatives are not appropriate. If it is denied there are further levels of appeal defined by CMS, beginning with redetermination by the plan.

Question 4

Why does the cheapest Part D plan sometimes cost more?

Accepted Answer

The Plan Finder estimate assumes every drug is approved and dispensed. It does not price in prior authorization, step therapy or quantity limits. A plan can be cheapest precisely because it restricts more, and a restricted drug that is denied costs you the full amount and does not count toward the out-of-pocket maximum.

Medicare Part D Prior Authorization & Step Therapy Checker