For certain prescription drugs, the plan has additional requirements for coverage or coverage limits. These requirements and limits ensure plan members use these drugs in the most effective way and help the plan control costs and can pass on savings to members. A team of doctors and pharmacists developed these requirements and limits to help the plan provide quality care to its members. Examples of utilization management are described below:
Prior Authorization: The plan requires you to get prior authorization for certain drugs. This means you will need to get approval from the plan before you fill your prescription. If you don’t get approval, the plan may not provide coverage for the drug.
Quantity Limit (QL): For certain drugs, the plan limits the amount of the drug it will cover per prescription or for a defined period of time.
Step Therapy (ST): In some cases, the plan requires you to first try one drug to treat your medical condition before it will provide coverage for another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, the plan will then provide coverage for Drug B.
Generic Substitution: When there is a generic version of a brand name drug available, the plan’s network pharmacies will automatically give you the generic version; unless your doctor has told the plan you must take the brand name drug.
You can find out if your drug is subject to these additional requirements or limits by looking at the plan's formulary. If your drug does have these additional restrictions or limits, you can ask the plan to make an exception to its coverage rules. You can request an exception to the formulary by using the form at the bottom of this web page.
Simply Healthcare has system edits in place that apply to claims at the pharmacy to make sure you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications or receives medications from more than one pharmacy. These edits look for medication problems such as:
Simply Healthcare or their designated provider will also review claims to determine the drug utilization patterns of members (i.e. over and under utilization) and physician’s prescription patterns. Simply Healthcare may contact physicians or members to discuss these utilization and prescribing patterns.
Members will also receive a monthly Explanation of Benefits (EOB) showing what medications were billed to Simply Healthcare under your account. Please review this information and call Member Services if there are any discrepancies.
Some prescription drugs require prior authorization (PA) or a medical exception for coverage. If your drug requires this step, your doctor will need to request and receive approval from Simply Healthcare before the drug may be covered under your benefit plan.
Why is Prior Authorization required?
Simply Healthcare requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from the plan before you fill your prescriptions, if you don't get approval, the plan may not cover the drug.
How do I get Prior Authorization for my prescription?
Follow the steps outlined below to receive coverage for medications requiring prior authorization:
Please use the links listed in this document to access the specific criteria set that applies to your plan.
What if your Drugs have Quantity Limits?
For certain drugs, Simply Healthcare limits the amount of the drug it will cover. For example, Simply Healthcare provides 30 tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to a standard one month or three month supply.
Access all of the quantity limits on Simply Healthcare Medicare Advantage Plan Part D prescription drugs.
What is Step Therapy?
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. If your drug has a step therapy requirement, we will need your doctor to request and receive approval from Simply Healthcare before the drug may be covered under your benefit plan.
Please use the links listed below to access the specific criteria set that applies to your plan.
You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have a medical reason that would justify asking the plan for an exception, your provider can help you request an exception to our utilization management tools; such as prior authorization, quantity limits, or step therapy requirements. You can ask the plan to cover a drug even though it is not on the plan's drug list, or you can ask the plan to cover the drug without restrictions.
You or your doctor may ask the plan to make an exception to its Part D Coverage Rules in a number of circumstances, for example:
