Utilization Management (Prior Authorization Requirements and Step Therapy Requirements)
Magnolia Health had a team of doctors and pharmacists create tools to help us provide quality coverage to our members. The tools include‚ but are not limited to: prior authorization and step therapy criteria‚ clinical edits and quantity limits. Some examples include:
- Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
- Quantity Limits: For certain drugs, Magnolia Health limits the amount of the drug we will cover per prescription or for a defined period of time.
- Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, Magnolia Health may not cover the drug.
- Step Therapy: For certain drugs, we require you to try a less expensive alternative before “stepping up” to drugs that cost more.
You can ask Magnolia Health to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to the Comprehensive Formulary. When you are requesting a utilization restriction exception you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination* form that is provided below. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.
- Maintenance Drug Program – Drugs that can be obtained as a 90 day supply; designated by MO
- Prior Authorization Criteria
- Quantity Limit Listing
- Step Therapy Criteria
- Request for Medicare Coverage Determination Form*
* Please note – You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).
You can contact Magnolia Health at any time for the most recent list of covered drugs. Phone numbers and hours of operation can be found at the bottom of this webpage.
Last Updated: 06/09/2017