Medicare Advantage Pharmacy Benefits

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members use these drugs in a safe way. The types of additional requirements are listed below:

Prior authorization (prior approval) – For certain drugs, your doctor or health care provider will need to contact us before you fill your prescription.

Step therapy – For certain drugs, we require you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Quality care dosing limits – For quality and safety reasons, there might be a limit on refills or how much of a drug can be received with each prescription. This process helps to ensure that the quantity and dosage of your medications remain consistent with manufacturer, clinical, and Food and Drug Administration (FDA) recommendations.

To see a complete list of drugs that require prior authorization or step therapy or have dosing limits, view the criteria documents below:

If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete the
PDF 2014 Request for Medicare Prescription Drug Coverage Determination Form and ask your doctor to fax it to us at
1-617-246-8506.