For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of pharmacists developed the following requirements and limits for our Plan to help us to provide quality coverage to our members:
Prior Authorization: We require you to get prior authorization for certain drugs. This means that you or your authorized representative will need to get approval from us before you fill your prescriptions. If they don’t get approval, we may not cover the drug.
Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 30 capsules per 30 day period for a prescription for Nexium.
Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. 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 does not work for you, then we will cover Drug B.
Generic Substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. Even if your doctor writes for the brand-name drug you may still need to request for coverage of the brand-name drug from the plan.
You can find out if the drug you take is subject to these additional requirements or limits by looking in the formulary. If your drug is subject to one of these additional restrictions or limits and your physician determines that you are not able to meet the additional restriction or limit for medical necessity reasons, you or your physician can request an exception (which is a type of coverage determination).
