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)
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)
Generic substitution
A brand name drug is a prescription drug sold under a trademarked name owned by the drug manufacturer. Biological products are drugs that are more complex than typical drugs. A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Biological products have alternatives called biosimilars. Generally, generics and biosimilars work just as well as the brand name drug or original biological product and usually cost less. There are generic drug substitutes available for many brand name drugs and biosimilar alternatives for some original biological products. Some biosimilars are interchangeable biosimilars and, depending on state law, may be substituted for the original biological product at the pharmacy without needing a new prescription, just like generic drugs can be substituted for brand name drugs. If there is a generic or interchangeable biosimilar available, our pharmacies will automatically give you the generic or biosimilar version. If your condition requires you must take the brand name drug, your doctor must submit a formulary exception request.
