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Coverage Requirements

For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. This ensures that our members safely use their medications.

Types of additional requirements

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.

Formulary quantity limit

For certain drugs, our plans limit the amount of the drug that our plans will cover. For example, our plans provide up to 30 tablets per 30 days per prescription of Simvastatin 10 mg tablets. This may be in addition to a standard one-month or three-month supply.

Non-formulary quantity limit

For certain drugs that are not covered on our formulary, our plans may limit the amount of the drug that our plans will cover if a formulary exception request is approved.

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Two criteria guidebooks next to each other

Requirements and criteria

Prior Authorization & Step Therapy Criteria

To see a complete list of drugs that require prior authorization or step therapy, view the documents below:

2024 Medicare Advantage Prior Authorization Criteria (Updated 11/01/2024)

2025 Medicare Advantage Prior Authorization Criteria (Updated 10/01/2024)

2024 Medicare Advantage Step Therapy Criteria (Updated 08/01/2024)

2025 Medicare Advantage Step Therapy Criteria (Updated 10/01/2024)

2024 Medicare Advantage Part D Non-Formulary Quantity Limit (Updated 01/01/2024)

If a medication you're taking requires prior authorization or step therapy, please download and complete the form below:

Providers please fax this form to 1-866-463-7700.

Members please fax this form to 1-617-246-8506.

Request for Medicare Prescription Drug Coverage Determination Form

Medicare Advantage Part B Coverage Requirements

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.

2024 Medicare Advantage Part B Step Therapy Program Drug List (Effective 05/01/2024)

2025 Medicare Advantage Part B Step Therapy Program Drug List (Effective 10/01/2024)

Our plans may require you to meet certain medical criteria before we will cover a medication. The document below outlines the list of medications that are currently part of the Medicare Advantage Part B Medical Utilization Management Program.

Medicare Advantage Part B Medical Utilization Management Criteria (Updated 03/01/2024)