For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members safely use their medications.
The types of additional requirements are:
- Prior authorization (prior approval) – Medications that require prior authorization are prescription medications that require your doctor to obtain approval from us in order to be covered. If your doctor doesn't get prior authorization from us before filling your prescription, you may be financially responsible for the full cost of the medication.
- Step therapy – Step Therapy allows us to help your doctor provide you with a drug treatment that is safe, effective, and affordable. Before coverage is allowed for certain costly "second-step" medications, you’re required to first try an effective and less expensive "first-step" medication. 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 doesn't work for you, then we'll cover Drug B.
Prior Authorization & Step Therapy Criteria
To see a complete list of drugs that require prior authorization or step therapy, view the documents below:
- 2019 Medicare Advantage Prior Authorization Criteria (Updated 11/01/2019)
- 2019 Medicare Advantage Step Therapy Criteria (Updated 11/01/2019)
- 2020 Medicare Advantage Prior Authorization Criteria(Updated 10/15/2019)
- 2020 Medicare Advantage Step Therapy Criteria (Updated 10/15/2019)
If a medication you're taking requires prior authorization or step therapy, please download and complete the form below, and ask your doctor to fax it to: 1-617-246-8506.
MEDICARE ADVANTAGE PART B STEP THERAPY PROGRAM (Applies to 2020 Plan Year only)
Our plans may require you to first try certain medications to treat your medical condition before we will cover another medication for that condition. The document below outlines the list of medications that are currently part of the Medicare Advantage Part B Step Therapy Program.