Prior Authorization and Step Therapy

Safety is Our Priority

New drugs and new drug information come to the market at an astounding pace. Additionally, a record number of drugs have been taken off the market because of safety issues that were identified after marketing.

In order to help assure our members have access to safe, effective drug therapy and to protect against inappropriate use and waste, we require prior authorization and step therapy on selected prescription medications.

Prior Authorization

Certain medications require prior authorization. This means that you will need to get approval before you fill your prescriptions. If you don't get approval, the drug may not be covered.

• 2024 Medicare Part D Prior Authorization PolicyOpen a PDF
• 2024 Dual Special Needs Plan (D-SNP) Prior Authorization PolicyOpen a PDF

Step Therapy

In some cases, we require you to first try certain drugs 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 not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

• 2024 Medicare Part D Step Therapy PolicyOpen a PDF
• 2024 Dual Special Needs Plan (D-SNP) Step Therapy PolicyOpen a PDF
• Medicare Part B Step Therapy PolicyOpen a PDF

Drugs that require Prior Authorization/Step Therapy are indicated on our drug list. To check if prior authorization or step therapy applies, search one of our online drug lists.

We have an exception process in place for drugs with prior authorization, step therapy, or other requirements or limits on coverage. If your healthcare provider determines that you need a medication that has a requirement or limit, he/she must submit a request supporting your need. Access the forms to request an exception.