Why we use prior
authorizations and
step therapy

Our goal is to provide our members with access to the safest, most effective, and reasonably priced drugs available. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, our plan rules encourage you and your prescriber to use the lower-cost option. These rules comply with Medicare regulations and help keep your drug coverage more affordable.

Prior authorization

Some prescription drugs require prior authorization. This means that before we will cover a particular drug, your doctor or prescriber must contact us to explain why the drug is medically necessary for you.

Step Therapy

With step therapy, you must first try a certain less expensive drug that has been proven effective before you can move up a “step” to a more expensive drug. For example, we may require you to try a higher cost generic drug before we will cover a more expensive brand-name drug.
You could get an exception to step therapy if:

  • You’ve already tried a similar or less expensive drug and it didn’t work
  • Your doctor or prescriber believes your condition requires use of a certain drug, even if it is more expensive

Exceptions

Exceptions can be granted when we determine that a requested drug is medically necessary. A doctor’s statement must be submitted with all such requests. The two types of exceptions are:

  • A tiering exception can be requested to obtain a drug at lower cost-sharing terms
  • A formulary exception can be requested to obtain a drug that’s not on our list or if you believe restrictions such as step therapy on a certain drug should not apply

To request an exception or get prior authorization fill out electronic form or download and print a blank Coverage Determination Request. Your doctor will need to fax this form to us at 1-855-633-7673.


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