Prior Authorization and Utilization Management
In prescription drug plans, prescription drugs are placed into tiers. The costs for drugs in each tier are different. Tier 1 drugs will cost less than Tier 5 drugs. The tiers are:
- Tier 1 — Preferred Generic Drugs
- Tier 2 — Generic Drugs
- Tier 3 — Preferred Brand Drugs
- Tier 4 — Non-Preferred Drugs
- Tier 5 — Specialty Drugs
Prior Authorization
Some drugs require prior approval before they are covered. This is so the plan can best guide the correct use of these drugs. Your doctor can help you get approval. To learn more about prior authorization, select the link below.
Prior Authorization Criteria and Form
Step Therapy
You may be asked to start treatment with a drug that costs less but works just as well (for example, a generic name drug) instead of starting with a drug that costs more. If the first drug doesn’t work for you, then the plan may cover the higher-priced drug. For more information about step therapy, select the link below.
Step Therapy Criteria and Form
Quantity Limits
There can be a limit on a drug you’re allowed which can include how many pills you get with each prescription. These limits are based on safety guidelines. To learn more about quantity limits, select the link below.
Quantity Limits Exception Form
Drug Utilization Review
Drug utilization reviews help make sure you’re getting safe and proper care. They are very important if you have more than one doctor prescribing your medications. The review is done each time you fill a prescription, as well as on a regular basis. We look for issues such as:
- Medication errors
- A drug that may not be needed because you are taking another drug to treat the same medical condition
- Drugs that are not right for you because of your age or sex
- Possible harmful interactions between drugs you are taking
- Drug allergies
- Dosage errors
If we find a problem during the review, we’ll work with your doctor to fix it.