Prior Authorization (PA)
A process where additional information must be provided or criteria must be met before certain medications can be dispensed. The criteria for which drugs require a PA are established by the plan sponsor.
Quantity Limits
Limit on the number of pills or dosages allowable per claim.
Single-source Brand
A drug product manufactured by one company or source. Single source drugs are those brand-name drugs that do not have a generic equivalent or generic alternative.
Specialty Drugs
Drugs manufactured through biologic processes to treat chronic, complex or life-threatening conditions.
Specialty Pharmacy Benefit
Coverage of drugs manufactured to treat chronic, complex or life-threatening conditions.
Step Therapy
Treatment guidelines used to recommend drug therapy beginning with the least expensive therapy. More expensive therapies are only used when the patient fails to respond to the first-line drug or after a Prior Authorization.
Therapeutic Substitution
Dispensing of a drug that is therapeutically equivalent to the originally prescribed drug.
Tier
Drugs on a formulary are grouped in different categories, or tiers, to represent copayment amounts. Lower drug tiers are associated with lower drug costs.