Step Therapy
A utilization rule requiring trial of lower-cost preferred drugs before the plan covers a higher-cost alternative in the same class.
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Practice This Concept
Under Medicare Part D rules, a plan's formulary must include at least:
Two drugs in each therapeutic category and class — Part D plans maintain formularies that must include at least two drugs in each therapeutic category and class, ensuring access to a meaningful range of treatments. Plans may use tiered cost-sharing and prior authorization, but the minimum formulary standard protects beneficiaries from plans that offer too narrow a drug list.
National insurance concept
A Medicare Part D prescription drug plan formulary must include...
At least two drugs in each therapeutic category and class. — CMS regulations require every Part D plan's formulary to include at least two drugs in each therapeutic category and class, so beneficiaries have a genuine choice of treatment within each disease area. Plans may use tiers and utilization management such as prior authorization and step therapy, but the two-drug minimum protects access. A formulary is not required to cover every FDA-approved drug, and plans routinely cover generic and brand products together. The two-drug-per-class minimum is the precise formulary standard tested in the Medicare Part D section of the senior health products outline.
National insurance concept
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