Prescription Benefits Prior Authorization, Step Therapy and Quantity Limits
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
| Prior Authorization | HNE Medicare Advantage required you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HNE Medicare Advantage before you fill your prescriptions. If you do not obtain approval, HNE Medicare Advantage may not cover the drug. |
| Step Therapy | In some cases, HNE Medicare Advantage requires 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, HNE Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HNE Medicare Advantage will then cover Drug B. |
| Quantity Limits | For certain drugs, HNE Medicare Advantage limits the amount of the drug that HNE Medicare Advantage will cover. For example, HNE Medicare Advantage provides six tablets per month per prescription for Zomig. This may be in addition to a standard one month or three month supply. |
| Online Requests |
You can find out if the drug you take is subject to these additional requirements or limits by selecting the above link or by calling Member Services. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you or your physician may request an exception (which is a type of coverage determination).
How do I request an exception to the HNE Medicare Advantage Plan Formulary?
You can ask HNE Medicare Advantage to make a coverage determination or exception to our coverage rules. There are several type of exceptions that you can ask us to make.
Generally, HNE Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
Forms:
To submit a request or check on the status of a request for a coverage determination or redetermination, use the “Online Requests” button above. Usually, your prescriber will submit a request on your behalf. You or your prescriber may also use the NPS Coverage Determination Request Form or CMS Medicare Part D Coverage Determination Request Form.
Where should I send my request?
You, your presciber, treating provider, or authorized representative may contact us by mail, fax, or telephone at one of the addresses, fax, or telephone numbers provided on the Initial Decisions, Appeals, and Grievances page.
H8578_2016_049 Approved
The information on this page was last updated on 2/18/2016