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) – 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.
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 5/1/2019)
- 2019 Medicare Advantage Step Therapy Criteria (Updated 5/1/2019)
If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete the and ask your doctor to fax it to us at 1-617-246-8506.