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Prior authorization, quantity limits & step therapy
Prior authorization, quantity limits & step therapy
Some drugs have coverage rules you need to follow. These include:
- Prior authorization
You or your doctor needs approval from us before we cover the drug. - Quantity limits
For certain drugs, there’s a limit on the amount of it you can fill within a certain timeframe. For example, 60 tablets per 30-day prescription. - Step therapy
We require you to try another drug first before we cover your drug.
There are two ways you, or your doctor can ask us to make an exception to one of our coverage rules.
1. Request an exception online
2. Call Customer Care at the number on your member ID card.
To learn more about requesting an exception, please refer to your Evidence of Coverage.
Transition rules
Transition rules
There may be times when you’re taking a drug that either isn’t on our formulary (drug list) or has coverage rules. A formulary shows the drugs we cover, the tier a drug is on, any limits or coverage rules and mail order availability.
Learn about our transition process to see if you’re eligible for a one-month supply of medication. This temporary supply allows you to work with your doctor to either transition to a new drug on our formulary or request an exception to continue your current drug.
