Utilization management for prescription drugs

Covered drug limits, additional requirements

Some drugs have special requirements that must be met before we'll cover them. Those requirements are:

• Step therapy drugs require your provider to first prescribe alternative options that are generally more cost effective without compromising quality. Step therapy may be waived if determined to be medically necessary.
• Prior authorization is required for certain drugs. This process must be completed by your doctor before you fill your prescription.
• Quantity limits on certain drugs to ensure safe use. 

If your physician believes you require a certain medication that is not on your formulary, normally requires step therapy or exceeds a quantity limit, he or she may request an exception through the preauthorization process.

Prior authorization

Some covered drugs require approval in advance to get coverage. Prior approval is used for drugs that are and are not on our formulary. Some medications are covered only if your doctor or other network provider gets a prior authorization from us. Covered medications that need prior authorization are marked in the formulary.

• 2024 prior authorization criteria - updated 12/1/24
• 2025 prior authorization criteria - updated 12/1/24
• Medica Central Health Plan Medicare D Coverage Determination form - updated 10/22/20

Note:

• Requests for coverage may be denied or dismissed unless all required information is received.
• Your provider’s office will receive a response via fax.
• For urgent requests, call 1-877-301-3326 (TTY: 711).

Step therapy

Before some medications are approved, a different medication must be tried first. This first medication may or may not require a prior authorization. 

• 2024 step therapy criteria - updated 12/1/24
• 2024 step B therapy criteria - updated 12/1/24
• 2025 step therapy criteria - updated 12/1/24
• 2025 step B therapy criteria - updated 11/1/24

Quantity limits

We require that some prescription drugs have quantity limits to ensure quality, safety and proper use. We may limit the amount of the medication we cover per prescription or for a defined period of time.

The quantity listed is the quantity-per-month limitation. The drug benefit typically allows coverage for a 30-day supply unless the medication is available at a 90-day supply through mail order or at retail location per prescription claim.

Notice of formulary updates

Generally, if you are taking a medication listed on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of that medication during the coverage year except when a new, less expensive generic medication becomes available or when information is released that calls into question the safety or effectiveness of a medication. Other types of formulary changes, such as removing a medication from our formulary, will not affect members who are currently taking that medication. It will remain available at the same cost-sharing for the remainder of the coverage year, except for in cases in which you can save additional money or we can ensure your safety.

Additional information for certain drug therapies 

Hospice Primary Billing form

BvD ESRD dialysis-related drugs

BvD TPN, IDPN, IPN

See the rest of our list of drugs with special requirements.