Prior Authorization & Step Therapy

Safety is Our Priority

New drugs and new drug information come to the market at an astounding pace. Additionally, a record number of drugs have been taken off the market because of safety issues that were identified after marketing. In order to help assure our members have access to safe, effective drug therapy and to protect against inappropriate use and waste, we require prior authorization and step therapy on selected prescription medications. For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the safest, most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult your copy of our formulary or Search Our Online Formulary for more information about these requirements and limits.

Certain medications require prior authorization. This means Simply Prescriptions must give its approval before you fill your prescriptions. If you don't get approval, the drug may not be covered.

2025 Medicare Part D Prior Authorization Policy (PDF)Open a PDF

In some cases, we require 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

2025 Medicare Part D Step Therapy Policy (PDF)Open a PDF

You can ask us to make an exception to our coverage rules, including waiving our prior authorization and step therapy restrictions on your drug. Access the forms to request an exception.

For information on the status of your exception request, please call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-662-1220) 8 a.m. to 8 p.m., Monday - Friday. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. to 8 p.m.

Simply Prescriptions contracts with the Federal Government and is a PDP plan with a Medicare contract. Enrollment in Simply Prescriptions depends on contract renewal. Submit feedback about your Medicare prescription drug plan at www.Medicare.gov or by contacting the Medicare Ombudsman. _.

This page last updated 10-01-2024.

 

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