Getting Approval for Your Medications
Some prescription drugs may require additional review before your plan can cover them. These requirements are called coverage rules.
Coverage rules are designed to help ensure medications are used safely, appropriately, and according to clinical guidelines. If a coverage rule is preventing you from getting the medication you need, you have rights and options available to you.
This page explains the most common prescription drug coverage rules and where to find additional information about coverage decisions, appeals, and exceptions.
Prescription drug coverage rules are different from the prior authorization process used for Medicare-covered medical services.
Understanding Coverage Rules
Your plan’s drug list (formulary) identifies which medications are covered and whether any coverage rules apply.
The most common coverage rules include prior authorization, step therapy, and quantity limits.
Prior Authorization
Prior authorization means your doctor or prescriber must request approval before your plan will cover a medication.
This review helps ensure the medication is medically necessary and appropriate for your condition.
If prior authorization is required:
- Your doctor submits a request to the plan.
- The request is reviewed using clinical criteria.
- A decision is issued within the required Medicare timeframes.
- If approved, your prescription can be filled.
- If denied, you have the right to request a coverage determination or appeal.
Step Therapy
Step therapy means you may be required to try one or more lower-cost or clinically preferred medications before coverage for another medication is approved.
If the first-step medication is not effective or causes side effects, your doctor may request an exception.
Step therapy may not apply if your doctor determines it is not medically appropriate for your situation.
Quantity Limits
Quantity limits restrict coverage to a specific amount of a medication per fill or within a certain time period.
These limits are based on FDA-approved dosing guidelines and clinical standards.
If your doctor believes you need a higher quantity for medical reasons, they may request an exception on your behalf.
Find Drug Coverage Information for Your Plan
Drug coverage requirements vary by plan. Select your plan to access your formulary, drug search tools, and coverage rule lists. Review medications that may require prior authorization or step therapy.
HMO-POS D-SNP
HMO-POS D-SNP
HMO-POS I-SNP/IE-SNP
HMO I-SNP
Need a Coverage Decision?
If you want to know whether a medication is covered, to request coverage for a drug that is not on the formulary, to request an exception, or to appeal a drug coverage decision, you may need a coverage determination.
Learn about coverage determinations, appeals, decision timeframes, and your rights under your Medicare prescription drug benefit.
Need an Exception?
If your medication is not on the formulary, is subject to a coverage rule, or is placed in a higher-cost tier, you may be able to request an exception.
Learn about formulary exceptions, tiering exceptions, and the information your doctor may need to provide.
Need Help?
If you have questions about your prescription drug coverage, formulary, or medication approval requirements, Member Services can help.