Step Therapy, Prior Authorization, Quantity limit, 7-DAY limit, Dispensing Limit and Limited Access are all examples of what?

• A. Coverage limitations.
• B. Utilization Management Rules.
• C. Provider enrollment criteria.
• D. Pharmacy benefit design.

Answer: (B)

These items are all examples of utilization management rules. Health plans and pharmacy benefit managers use these controls to influence how medications are used, aiming for safety, appropriateness, and cost containment. Step therapy requires trying a preferred, typically lower-cost option before moving to a higher-cost drug. Prior authorization needs an approval before a drug is covered, ensuring justification for its use. Quantity limits and dispensing limits cap how much can be dispensed or over what time frame, preventing overuse and encouraging appropriate dosing. Limited access restricts coverage or access to certain drugs for specific members or situations. Collectively, these rules shape how the pharmacy benefit is used, which is the essence of utilization management.