Coverage Determinations, Prior Authorization & Step Therapy Criteria

There may be times when you need to prescribe a drug that is not on the formulary or has certain utilization edits in place such as step-therapy, quantity limit or prior-authorization requirements. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.

Prior Authorization
Before it will cover these drugs, the plan needs more information from you to make sure the drug is being used correctly for a medical condition covered by Medicare. Your patient may be required to try a different drug before the plan will cover these drugs. If you do not get approval from the plan for a drug with a requirement or limit before using it, your patient may be responsible for paying the full cost of the drug. View the prior authorization criteria used by the plan to determine if the drug is covered.

2012 Prior Authorization Criteria (PDF) – Formulary F12 - For members of the Physicians Health Choice Total (HMO) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas; members of the Physicians Health Choice Select (HMO SNP) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas

Prior Authorization Form

Specialty Pharmacy Prior Authorization Form

Step Therapy

There are effective, lower-cost drugs that treat the same medical condition as these drugs. Your patient may be required to try one or more of these other drugs before the plan will cover their drug. If your patient has already tried other drugs or you think they are not right for your patient, you can ask the plan to cover these drugs. If you do not get approval from the plan for a drug with a requirement or limit before using it, your patient may be responsible for paying the full cost of the drug.

2012 Step Therapy Criteria (PDF) – Formulary F12 - For members of the Physicians Health Choice Total (HMO) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas; members of the Physicians Health Choice Select (HMO SNP) plan in Aransas, Kleberg, Nueces, San Patricio, Hays, Travis, Williamson, El Paso, Cameron, Hidalgo, Willacy Counties, Texas

Quantity Limits

The plan will only cover a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If you prescribe more than this amount or think the limit is not right for your patient's situation, you can ask the plan to cover the additional quantity.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN’S COVERAGE RULES

• Coverage for a drug not on the formulary. If an exception is approved, you would get the prescription drug at the Tier 3 copay level.
• More coverage for your drug(s). If your generic or brand drug is in Tier 3, you can ask that the plan to cover it as a Tier 2 generic or brand drug, so long as there is a generic or brand drug in Tier 2 for treating the same condition that the requested generic or brand Tier 3 drug is being used to treat. This would lower the amount you must pay for your drug. Likewise, you can ask the plan to cover a Tier 2 generic drug at the Tier 1 copay level so long as there is a generic drug in Tier 1 for treating the same condition that the requested Tier 2 generic drug is being used to treat. Note: If the plan grants your request to cover a drug that is not on the formulary, you may not ask the plan to provide a higher level of coverage for the drug.

Generally, your request for an exception will be approved only if the alternative drugs included on the plan’s formulary or the lower-tiered drug would not be as effective in treating your condition or would cause you to have adverse medical effects.

Download this form to request a coverage determination (including a benefits exception):

• Medicare Part D Coverage Determination Request Form (PDF) – for use by members and providers

This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members.

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