Controlling Plan Costs with Prior Authorizations, Step Therapy and Quantity Limits

Prior Authorizations

Amwins Rx implements Prior Authorizations as a cost-savings feature to the plan. Prior Authorizations ensure prescriptions are properly selected and can identify when improper prescribing may be occuring.

Amwins Rx formularies clearly indicate which prescription drugs require Prior Authorization before the prescription can be filled. Quantity limits on certain drugs will also be clearly identified on the Formulary.

Common reasons a prescription may be rejected by the pharmacy include;

• The drug is not on the Part D plan's Formulary
• A physician did not receive prior approval from the Part D plan for the prescribed medication
• The specific drug dosage, administration method (liquid vs. pill) or type (generic vs. brand) is not on the plan's Formulary
• A previously covered drug is no longer on the Formulary
• The pharmacy filling the prescription is not within the Part D plan's network
• The prescribed medication is not a Part D-covered drug
   

You can request a Prior Authorization or view the status of a recently requested PA directly through your Amwins Rx Member Portal.

Step Therapy

Amwins Rx continuously searches for ways to help control drug costs. One strategy for reducing overall drug cost is step therapy. Step therapy ensures members are receiving the safest, most effective and reasonably-priced prescription available to them.

When step therapy is implemented, less expensive drug options are presented before moving on to drugs that cost more. For example, a member may have symptoms consistent with allergies. With step therapy, and over-the-counter medication would be suggested first. If symptoms persist, a Tier 1 medication can be prescribed. After that, if the patient is not experiencing adequate relief, a Tier 3 medication would be prescribed.

Since the plan followed the step therapy protocols in the aforementioned process, there was ample opportunity for the least expensive solution to work. When implemented across an entire population, unnecessary spending on higher tier medications can be reduced and result in plan savings.

Quantity Limits

In order to maximize safety while controlling costs, Amwins Rx sets quantity limits on the amount of drugs that are covered over defined periods of time. For example, a member may receive a prescription with instructions to take 2 tablets per day for 30 days - totaling 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that particular medication, then the presciber will have to reach out to the plan to get authorization for the higher quantity.