Certain covered drugs have special rules or limits, like step-therapy, preauthorization, and quantity limits, to keep you safe. Learn more about these and which drugs have them.
How do I request a coverage determination or medical exception for a drug?
Step-Therapy
Step-therapy helps control your costs for some kinds of drugs. If we say a certain drug requires step-therapy, you have to try the cheapest drug in that category first. We call this a prerequisite medication.
In most cases, this drug will work for you. If it doesn’t, or if a doctor thinks it’s medically necessary to skip the prerequisite, they can request preauthorization.
Drugs that need step-therapy are marked in our formularies, or you can check this list:
Preauthorization
Preauthorization is approval of a drug or medical procedure before you get it. It's a review process to make sure that you meet certain requirements before we agree to cover it.
This is to help keep you safe and to control your costs.
Quantity Limits
This is a limit to how much of a drug we'll cover per prescription or over a certain period of time.
For example, if it’s considered safe to take only one pill per day of a certain drug, we may only cover that drug for one pill per day.
Quality Assurance Procedures
We have quality assurance policies in place to protect you. For details, check your plan's Evidence of Coverage in the chapters “Using the plan’s coverage for your medical service” and “Using the plan’s coverage for your Part D prescription drugs.”
Part B Versus Part D Drugs
Drugs that are identified as Part B versus Part D may be covered under Medicare Part B or D depending upon the situation. More info may need to be submitted describing the use and setting of the drug to determine what it should be covered under. You or your doctor will be contacted in this situation.