Prior Authorization, Step Therapy and Quantity Limits

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. Drugs that require a prior authorization are noted with a “PA or PA-NS” on the List of Drugs (formulary).
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This requirement to try a different drug first is called step therapy. Drugs that require step therapy are noted with an “ST” on the List of Drugs (formulary).
• Quantity Limits: For certain drugs, our plan limits 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. Drugs that require quantity limits are noted with “QL” on the List of Drugs (formulary).
• 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)December 2, 2024

• Step Therapy Criteria - (PDF)Oct 15, 2023

• Quantity Limits - Refer to the List of Drugs (Formulary) for drug requirements and limits.

• Part B Step Therapy - English (PDF)
• Part B Step Therapy - Spanish (PDF)

You can ask us to make an exception to our coverage rules. To learn about the specific types of exceptions, refer to your Member Handbook. When asking for an exception, include a statement from your doctor that supports your request, plus a completed Coverage Determination form.

Generally, 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. If we approve your expedited request, we must give you a decision within 24 hours after we get your doctor’s supporting statement.

Refer to the Coverage Determinations and Redeterminations page for more information.

If you have questions or want to get the most recent list of drugs, contact Member Services. We are here to help.

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. Drugs that require a prior authorization are noted with a “PA" or "PA-NS” on the List of Drugs (formulary).
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This requirement to try a different drug first is called step therapy. Drugs that require step therapy are noted with an “ST” on the List of Drugs (formulary).
• Quantity Limits: For certain drugs, our plan limits 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. Drugs that require quantity limits are noted with “QL” on the List of Drugs (formulary).
• 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 - English (PDF) November 7, 2024

• Step Therapy Criteria - English (PDF)October 15, 2024

• Quantity Limits - Refer to the List of Drugs (Formulary) for drug requirements and limits.

• Part B Step Therapy (PDF)

Drug Coverage Determinations

You can ask us to make an exception to our coverage rules. To learn about the specific types of exceptions, refer to your Member Handbook . When asking for an exception, include a statement from your doctor that supports your request, plus a completed Coverage Determination form.

Generally, 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. If we approve your expedited request, we must give you a decision within 24 hours after we get your doctor’s supporting statement.

Refer to the Coverage Determinations and Redeterminations for Drugs page for more information.

If you have questions or want to get the most recent list of drugs, contact Member Services. We are here to help.