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This is a process that requires you first to try one drug before your plan will cover another drug.

For example, if Drug A and Drug B treat the same medical condition, Health Alliance Medicare may require you to try Drug A first. If Drug A doesn’t work for you, we will then cover Drug B. This requirement encourages you to try safer or more effective drugs before we will cover another drug. Drugs that require step therapy are marked in our Medicare Part D Formulary.

Prior authorization is approval in advance from your health plan to get certain drugs or medical services.

For certain drugs to be covered, you need prior authorization from Health Alliance Medicare. This approval helps guide appropriate use of certain medications. Drugs Health Alliance Medicare covers that require prior authorization are marked in our Medicare Part D Formulary.

(For certain medical services to be covered, Health Alliance Medicare requires you or your doctor to get prior authorization. Services we cover that require prior authorization are listed in our Evidence of Coverage.)

This is a limit to the amount of a drug Health Alliance Medicare will cover per prescription or for a specific period of time.

There may be a limit to how many refills of a certain drug you can get or how much of a certain drug you can get each time you fill a prescription. For example, if it’s normally considered safe to take only one pill per day of a certain drug, Health Alliance Medicare may only cover your prescription for no more than one pill per day. Drugs that have quantity limits are marked in our Medicare Part D Formulary.

Health Alliance Medicare has established quality assurance policies, including drug and utilization management. View the Evidence of Coverage chapters “Using the plan’s coverage for your medical service” and “Using the plan’s coverage for your Part D prescription drugs” to learn more about these processes and procedures.