Part D Drug Management Tools
In addition to formularies and cost sharing tiers, Part D plans use a variety of prescription drug benefit management tools including:
•Step therapy: One or more similar lower-cost drugs must be tried before other costlier drugs are covered, if necessary.
•Prior authorization: Requires the doctor to contact the plan and request authorization before the plan will cover the prescription drug. The doctor must show the plan that the drug is medically necessary for it to be covered.
•Substitution: Part D sponsors may substitute generic drugs for brand name drugs if the generic drugs have the same or lower cost-sharing and certain conditions are met.
•Comprehensive Addiction and Recovery Act (CARA) programs: Plans may impose certain limitations on the prescribers or pharmacies a beneficiary can use to manage utilization for beneficiaries who are at risk of misusing or abusing frequently abused drugs, such as opioids.
