Utilization Management

For certain prescription drugs, Alliance Medicare PPO, HAP Senior Plus and Alliance Medicare Rx have additional requirements for coverage or limits on coverage. A team of doctors and pharmacists developed these requirements and limits to help us provide quality care and also help us control drug plan costs.

Prior Authorization (PA)

We require you to get prior authorization for certain drugs to be certain these drugs are used correctly and only when truly necessary. This means that you will need to get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.

Learn more about Prior Authorization Criteria (PDF)

Part B versus Part D Prior Authorization (B/D)

Some prescription drugs require a prior authorization to determine whether they should be covered under Part B or Part D. These drugs may be covered under either part depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug in order for us to make a determination on how to cover.

Learn more about Part B versus Part D Prior Authorization Criteria (PDF)

Quantity Limits (QL)

For certain drugs, we limit the amount of the drug that we will cover per prescription over a defined period of time.

Learn more about Quantity Limits (PDF)

Step Therapy (ST)

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, we will then cover Drug B.

Learn more about Step Therapy Criteria (PDF)

Generic Substitution

When there is a generic version of a brand name drug available, our plan pharmacies will automatically give you the generic version. If your condition requires that you must take the brand name drug, your physician must submit a prior authorization request.

You can find out if a drug you take is subject to these additional requirements or limits by looking in the Formulary (PDF).

If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules.

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