Prior Authorization/Step Therapy
Prior Authorization is when certain covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions require prior approval before use. The approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.
Step Therapy is when Independence requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Independence may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Independence will then cover Drug B.
For our list of drug formularies and utilization management documents, visit our Prescription Drugs section.
How to Submit a Prior Authorization/Step Therapy Request
A request form is available for medications requiring prior authorization. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative or your prescriber would like to initiate a prior authorization request, please submit a coverage determination. For more information on coverage determinations, including how to submit, please reference the Coverage Determinations for Part D section of our website.
Tiered Cost-Sharing and Formulary Exceptions
The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. For drugs in the non-preferred drugs tier, you and your provider can ask the plan to make an exception to allow at the preferred drug tier so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See instructions below for requesting an exception.
If the non-preferred request is approved, the drug will be processed at the appropriate preferred formulary benefit cost-sharing. If the request for access at the preferred tier is denied, you and your physician will receive a denial letter that explains the appeal process. You may still receive benefits for the drug at the non-preferred cost-sharing.
Please note that certain drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs for the following:
- Specialty tier
- Preferred brand
- Cost-share based on coverage phases, such as the coverage gap.
If your drug is not on the plan's List of Covered Drugs (Formulary) or is on the list but has a quantity limit, you can request an exception and ask the plan to cover the drug or cover a greater quantity of the drug than what the plan allows. 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 medical reasons that justify asking us for a quantity limit exception, your provider can help you request an exception to the rule. Drugs approved for formulary exception will always pay at the non-preferred tier and cannot be approved for tier exception.
How to Submit a Tier Cost-Sharing or Formulary Exception Request
A request form is available for submitting an exception request. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests. If you, your appointed representative or your prescriber would like to initiate an exception request, please submit a coverage determination. Please note that if you are approved for a formulary exception you are not permitted to also request a tier exception for that same drug. For more information on coverage determinations, including how to submit, please reference the Coverage Determinations for Part D section of our website.
Medicare Part B vs. Part D Determinations
CMS limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed and/or administered. Please refer to the appropriate formulary to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the Medicare Administrative Prior Authorization for Part B/D coverage form if needed. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
Certain drugs are generally only covered under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require precertification. Please see the attachment below to determine if precertification is required:
Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under Medicare Part B benefit.
Hospice Medicare Coverage
Effective July 18, 2014, the Centers for Medicare & Medicaid Services (CMS) adjusted prescription coverage guidelines for Medicare members with Part D coverage who are under hospice care.
CMS requires Medicare beneficiaries with Part D coverage who are under hospice care to get prior authorization for prescriptions that fall under these four classes of medications: analgesics, anti-nauseants (anti-emetics), laxatives and anti-anxiety drugs. These medications will be covered under Medicare Part D only if they are prescribed for diagnoses unrelated to the member's terminal illness.
If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please fill out the necessary information using the Hospice Information for Medicare Part D request form. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests.
- This Hospice Information for Medicare Part D request form may be printed and faxed to FutureScripts® Secure once completed at 1-888-671-5285.
- When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will require an outreach to your office to obtain additional information.
- Fax completed forms to FutureScripts® Secure for review at 1-888-671-5285. Make sure that your office telephone and fax numbers are included on the form.
- You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied.
- If you have not received a response 72 hours after submitting complete information, contact FutureScripts® Secure at 1-888-678-7015, Option 1.
- You, your authorized representative, or your physician may fax the Hospice Information for Medicare Part D request form to FutureScripts® Secure for review at 1-888-671-5285.
- Complete the prior authorization form. All requested information must be supplied. Note: FutureScripts® Secure may need to reach out to your provider for additional information.
- You may take the appropriate request form to your physician to be completed and faxed to FutureScripts® Secure for review at 1-888-671-5285. If you have not received a response from FutureScripts® Secure after 72 hours, you may contact the provider who made the request on your behalf or FutureScripts® Secure directly at 1-888-678-7015.
- If you have questions, please contact Member Help Team.
Website Last Updated: 3/1/2017
Y0041_HM_17_43499g Approved 3/31/2017