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.
- 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
- Prior Authorization Criteria (HMO) - English (PDF)
- Prior Authorization Criteria (HMO) - Spanish (PDF)
Step Therapy Criteria
- Refer to the List of Drugs (Formulary) for drug requirements and limits.
You can ask us to make an exception to our coverage rules. For specific types of exceptions, refer to the Evidence of Coverage or the Coverage Determination and Redetermination for Drug page.
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 2020 information for more details.