Medicare Advantage Utilization Management for Prescription Drugs, Medicare - Dean Health Plan

Skip to Content

Published on November 01, 2017

Utilization Management for Prescription Drugs

Some covered medications have additional requirements or limits on coverage. Limits on coverage include prior authorization, step therapy and quantity limits. If a medication you are taking has prior authorization, step therapy requirements or quantity limitations, please download and complete the specific drug’s prior authorization form and ask your doctor or other prescriber to fax it to us at 1-855-668-8552.

Prior Authorization

Some covered drugs require approval in advance to get coverage. Prior approval is used for drugs that are and are not on our formulary. Some medications are covered only if your doctor or other network provider gets a prior authorization form us. Covered medications that need prior authorization are marked in the formulary.

2018 Prior Authorization Criteria

2017 Prior Authorization Criteria

Prior Authorization Forms

Please Note:

  • Requests for coverage may be denied or dismissed unless all required information is received.
  • Your provider’s office will receive a response via fax.
  • For urgent requests, please call 1-866-270-3877 (TTY: 711).

Step Therapy

Prior to receiving coverage, a trial of another medication(s) is necessary. A Prior Authorization form may be required. Some medications do not require a PA form/exception request if the prior medication(s) have been filled within the pharmacy claims system.

2018 Step Therapy Criteria

2017 Step Therapy Criteria

Quantity Limits

Dean Advantage requires that some prescription drugs have quantity limits to ensure quality, safety and proper use. We may limit to amount of the medication we cover per prescription or for a defined period of time.

The quantity listed is the quantity per month limitation. For Dean Advantage, the drug benefit typically allows coverage for a 34-day supply unless the medication is available at a 90-day-at-retail location per prescription claim. For medications with a higher strength available, members must use the higher strength with any dose increases. If a member requires a higher quantity per month, prior authorization is required.

Notice of Formulary Updates

Generally, if you are taking a medication on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of that medication during the coverage year except when a new, less expensive generic medication becomes available or when information is released that calls into question the safety or effectiveness of a medication. Other types of formulary changes, such as removing a medication from our formulary, will not affect members who are currently taking that medication. It will remain available at the same cost-sharing for the remainder of the coverage year, except for in cases in which you can save additional money or we can ensure your safety.

Dean Advantage is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Dean Advantage depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. You must continue to pay your Medicare Part B premium. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. We also list pharmacies that are in our network but are outside the Dean Advantage service area.

H9096_WEB18v1 Approved

Contact us

Talk to a Dean Medicare representative by calling
1-877-234-0126 (TTY: 711)
8 am to 8 pm, weekdays (year-round) and weekends (Oct. 1 – Feb. 14).

For information in alternate formats and languages, call the number above.

Mailing Address:
Dean Health Plan
PO Box 56099
Madison, WI 53705

  • Connect with us on Facebook
  • See us on YouTube
  • Connect with us on LinkedIn

© 2017 Dean Health Plan, Inc. | All rights reserved.

A Member of SSM Health

SSM Health and the infinity symbol are trademarks of SSM Health and its affiliates.