Utilization management
Learn if your drugs have coverage restrictions or limits
HAP HMO, HMO-POS, PPO and D-SNP plans have additional requirements for coverage or limits on coverage for certain prescription drugs. A team of doctors and pharmacists developed these requirements and limits to help us provide quality care and control drug plan costs.
Find out if a drug you take is subject to these additional requirements or limits by searching for your medication in our 2025 Medicare formulary, also known as a drug list. To search drug list press Ctrl+F (Command+F for Mac) and type in the name of the drug to see whether it’s included in the covered drug list for your type of plan. The drug name will be highlighted.
If your drug has additional restrictions or limits, you can ask us to make an exception to our coverage rules.
Prior authorization
We require you get approval from us before you fill certain prescriptions. This gives us a chance to be certain these drugs are used correctly and only when truly necessary. If you don’t get prior authorization, we may not cover the drug.
Learn more about prior authorization criteria (2025)
Learn more about prior authorization criteria (2026)
Part B versus Part D prior authorization
Some prescription drugs require prior authorization to determine whether they should be covered under Medicare Part B or Part D. These drugs may be covered under either part depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug in order for us to determine how to cover it. Drugs requiring this review have a B/D next to them on the drug list.
Quantity limits
We limit the amounts of certain drugs we’ll cover per prescription over a defined period of time.
Step therapy
In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, we will then cover Drug B.
Learn more about step therapy for Part D drugs (2025)
Learn more about step therapy for Part D drugs (2026)
Generic substitution
A brand name drug is a prescription medicine sold under a special, trademarked name by the company that makes it. Some drugs, called biological products, are more complex than regular drugs.
A generic drug has the same active ingredients as a brand name drug but usually costs less. A biosimilar is a close copy of a biological product and also typically costs less.
Many brand name drugs have generic versions, and some biological products have biosimilar versions. Some biosimilars are called interchangeable biosimilars, which means they can be swapped in at the pharmacy (like generics), depending on state laws.
If a generic or interchangeable biosimilar is available, the pharmacy will usually give you that version automatically. If you need the brand name drug instead, your doctor must request special approval (a formulary exception).
