What is Prior Authorization?
Prior Authorization (PA), is part of our Utilization Management (UM) program and refers to a process required for some prescription drugs to be covered by Elderplan. If your medication needs PA, you, your representative, or your doctor must request to get an approval from Elderplan before you fill your prescription. Without this approval, Elderplan may not cover the drug.
Why is Prior Authorization required?
PA ensures that you get the best use of your benefits and receive the most suitable treatment. For example, if your doctor prescribes a new diabetes medication, Elderplan may need to approve it before you can fill the prescription.
As part of our Prior Authorization process, we adhere to additional requirements, such as Step Therapy and Quantity Limits. Check Elderplan’s Prior Authorization Approval List to see if your medication requires authorization. You can also use the searchable formulary to determine if PA is needed.
Step Therapy (ST)
What is Step Therapy?
Step Therapy is part of the PA program. It ensures you receive appropriate and affordable treatment. Elderplan may require you to try certain drugs before covering another drug for the same condition. For example, if Drug A and Drug B treat your condition, Elderplan may only cover Drug B if Drug A is tried first and found ineffective.
Why is Step Therapy required?
Step Therapy promotes the safe and cost-effective use of medications. You must try first-line medications, known to be safe and effective, before using second-line medications, which may be more expensive. Check the lists for drugs that fall under these criteria:
Quantity Limits (QL)
What are Quantity Limits?
Quantity Limits (QL) restrict the amount of medication covered per prescription or within a set period. If you need more than the allowed amount, your doctor must submit a supporting statement to Elderplan. Approval is needed before you fill your prescription for the additional quantity.
Why are Quantity Limits Required?
QLs are based on manufacturer dosing guidelines and current medical recommendations to prevent medication misuse and abuse. Prescriptions exceeding the limits will need authorization before being filled.
If necessary, you may file an exception on certain restrictions. For more information visit our Exceptions section on the Frequently Asked Questions.
