Prior Authorization, Step Therapy and Quantity Limits
Buckeye Health Plan has a team of doctors and pharmacists who create tools to help us offer benefits to our members. Some of the tools are listed and described below:
- Prior Authorization: We require you to get approval from us agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug.
- Step Therapy: Some drugs require you to try a less expensive drug before “stepping up” to drugs that cost more.
- Quantity Limits: Some drugs limit the number of pills for a specific number of days.
- Age Limits: Some drugs require approval if your age does not meet what is advised by the FDA or clinical recommendations.
You can ask Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) to make an exception to our coverage rules.
We must decide within 72 hours of getting the note and form from your doctor. You or your doctor can request an expedited (fast) exception if your health is in danger. If the request for a fast exception is allowed, we must tell you our decision within 24 hours of getting the note and form from your doctor.
* Please note – This form cannot be used for Medicare non-covered drugs. Fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, and prescription vitamins (except prenatal vitamins and fluoride preparations) are examples of Medicare non-covered drugs.
Call Buckeye Health Plan for the most recent list of covered drugs. For questions, please call the Member Services department at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.
Last Updated: 03/02/2018
Our plan has a team of doctors and pharmacists who create tools to help us provide you quality coverage. Examples are:
- Prior Authorization: We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug.
- Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, one tablet per day. This may be in addition to a standard one-month or three-month supply.
- Age Limits: Some drugs require a prior authorization if your age does not meet drug manufacturer, Food and Drug Administration (FDA), or clinical recommendations.
- Prior Authorization Criteria (PDF)
- Quantity Limits
- Step Therapy Criteria - English (PDF)
- Step Therapy Criteria - Spanish (PDF)
Refer to the List of Drugs (Formulary) for drug requirements and limits.
We must decide within 72 hours of getting your doctor’s supporting statement. You or your doctor can request a fast (expedited) exception if your health may be harmed by waiting. Your doctor must submit a supporting statement with the Coverage Determination form. If we grant your request, we must give you a decision no later than 24 hours after we get your doctor’s supporting statement.
See the Coverage Determinations and Redeterminations for Drugs page for more information.
If you have questions about our list of drugs or want to get the most recent list of drugs, contact Member Services. We are here to help
Last updated: 10/04/2018