Understanding Your Prescription Insurance: Definitions of Prior Authorization and Quantity Limits

Overview of Limits and Authorization

Quantity limits and Prior Authorization can be a frustrating part of the prescription plan. All plans, for the most part, have such limitations and hopefully you won't be unfortunate to have to deal with that aspect. If you are unsure as to whether your plan has a limit or authorization required, you can call your prescription benefit manager or go to their website. The information is usually ready and available.

It is best to know ahead of time, it is a pain to get to the pharmacy to pick up your prescription, only to be told that it isn't covered by your plan. It is important to remember that this is not your pharmacists fault and it is not your prescription benefit manager's fault. The plan is set up by your provider. However, there are things you can do like getting a prior authorization for your drug that can hopefully help get your drug covered.

Quantity Limits for Prescription Drugs

If you have a prescription drug plan, it more than likely has a list of drugs that have quantity limits. Most of the time these are drugs that are specified by the drug manufacturer as short term drugs, requiring tests to determine necessity, and controlled substances.

To learn if your plan has a quanity limit, you can call your prescription plan customer care, the number is usually located on your id card and they can tell you. Not all drugs have a quantity limit.

Definition: This is a specific quantity of a particular drug that you are allowed an allotted amount of that drug withing a window of time. Anything more than the quantity limit will not be covered by the plan and will have to be paid for out of your pocket at the full retail cost.

Example: (These are not standard for all plans, simply examples)

  • Viagra can be dispensed 8 pills in a 30 day window.
  • Ambien can be dispensed 15 pills in a 30 day window.

This means that a covered person may only receive 8 pills of Viagra in a 30 day period, and the prescription plan will count each and every pill billed to the insurance. If you attempt to go over this limit, the claim will reject.

Drugs that might require quantity limits: Sleep agents, erectile dysfunction drugs, controlled substances

Prior Authorization

So what if you need more than your prescription plan will allow? That is where a Prior Authorization comes into play. Prescription plans understand that sometimes your therapy may fall outside the guidelines put into place. In most cases a Prior Authorization might be able to be obtained if your doctor can give a well documented and supported claim as to why you need more than what your plan will allow for.

Definition: Refers to a medication that is needed by the member that is not covered by the plan. Usually the medication requires a diagnosis or testing for authorization. The medication will only be covered if the prescription plan gives the approval or authorizes the coverage once the member passes certain clinical criteria.

A prior authorization could be required to exceed the quantity limits on your prescription plan or to get a drug covered that would not normally be covered. Your customer service representative cannot give you the criteria, as they cannot coach you into getting coverage. Usually your doctor's nurse or authorized agent will need to call or fax in information pertaining to the necessity of the drug for your condition.

Your prescription plan sets up the criteria for which they will approve this special authorization. It is important to remember that a prior authorization is not a prescription. If your drug requires a prior authorization, you will need both pieces of information. A prescription is approval from your doctor to take the medication and a prior authorization is approval from your prescription plan to approve coverage on your doctor's recommendations.

Drugs that might require a prior authorization: Proton Pump Inhibitors such as Nexium or Prevacid, Sleep agents, controlled substances, higher cost drugs


If your Prior Authorization is denied?

There are times when your prior authorization is denied. It could be for many different reasons. In most cases, you are entitled to know the reasons for denial. You should ask your customer service representative for a copy. Keep in mind that the denial comes from your prescription plan.

There are a few things you can do in the event that your prior authorization is denied:

  • Re-request a prior authorization - Some plans will allow you to try the prior authorization process again. You will need to ask about the specifics on the procedure for re-requesting. Each plan is different.
  • Appeals - This is subject to your prescription plan. Sometimes they will allow you to try to appeal the decision to deny. When you get a denial, you will probably get a letter explaining that your request is denied. It will likely have steps listed to start an appeals. Appeals are lengthy and require quite a bit more information than a normal Prior Authorization. Some plans may require testing and medical records to make their decisions, as well as a letter of medical necessity from the doctor.

Keep in mind that your prescription plan is not stating that you cannot have the medication, only that they will not pay for what you are requesting. While this can be disheartening and frustrating, it is a fact of the prescription insurance business. Usually, the most common reason why you need a prior authorization is because you're therapy falls outside the normal manufacturer guidelines. This means that your insurance plan wants to cover themselves for safety and appropriate use before they cover certain drugs.

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4 comments

Happyboomernurse profile image

Happyboomernurse 6 years ago from South Carolina

I'm a nurse who was considering writing a hub on this topic, but I see you've already done a great job on it. Thanks for sharing this useful information.


rgarnett profile image

rgarnett 6 years ago from KC, MO Author

Thanks so much for your comments, I am pleased to know that someone finds this hub useful! :)


crazybeanrider profile image

crazybeanrider 3 years ago from Washington MI

Good information. My mom has run into the problem of the doctor refusing to preauthorize any medications. The excuse being to much paperwork. It is hard enough getting the right med, but to have a doctor refuse to authorize is obscene.


rgarnett profile image

rgarnett 3 years ago from KC, MO Author

@crazybeanrider, this is absolutely correct. Unfortunately, doctor's are annoyed by the process, but it's necessary if they want their patient to get the medication through the insurance.

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