Utilization management for prescription drugs

Requirements + limitations

Some covered medications have additional prior authorization and step therapy requirements as well as quantity limitations. If your medication has any of these restrictions, please complete the appropriate prior authorization form and ask your 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 from us. Covered medications that need prior authorization are marked in the formulary.

• Prior authorization criteria (PDF) updated 4/1/24
• Medicare D coverage determination form (PDF) updated 6/14/22

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 some medications being approved, a different medication must be tried first. This first medication may or may not require a prior authorization.

• Step Therapy Criteria (PDF) updated 4/1/24
• Medical Step B therapy criteria (PDF) updated 4/1/24

Quantity limits

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

The quantity listed is a per-month limitation. Our drug benefit typically allows coverage for a 30-day supply, unless a 90-day supply of the medication is available at a retail location. If you have a dose increase, you'll be required to use a higher strength medication, if available. If you need a higher quantity per month, prior authorization is required.

Notice of formulary updates

If your medication is on our formulary and was covered at the start of the year, we typically won't discontinue or reduce your coverage of that medication during the year. However, if a less expensive generic option becomes available or if there's a concern about your medication's safety or effectiveness, that drug's coverage may change.

Other changes to the formulary, like removing a medication, won't affect you if you're currently taking that medication. It will remain available to you at the same cost-sharing rate for the rest of the covered year, unless you can save additional money or there is a safety concern.

Additional information for certain drug therapies

Hospice Primary Billing form
BvD ESRD dialysis-related drugs
BvD TPN, IDPN, IPN