Certain covered drugs have special rules or limits, like step therapy, prior authorization, and quantity limits, to keep you safe. Learn more about these and which drugs have them.
How do I request a coverage determination or medical exception for a drug?
Step Therapy
A process requiring you to first try one drug before we agree to cover another drug. If Drug A and Drug B treat the same medical condition, Health Alliance may require you to try Drug A first. If Drug A doesn’t work for you, we will then cover Drug B. This requirement encourages you to try safer or more effective drugs before we will cover another drug.
Drugs that need step therapy are marked in our formulary, or you can check this list:
Prior Authorization
Prior Authorization is a review process your doctor must request for a specific drug or service to make sure you meet certain requirements before the health plan agrees to cover it.
This is to help keep you safe and to control your costs.
Quantity Limits
Policy that limits the amount of certain drugs you’re given based on the drug maker’s package size and what the Food and Drug Administration (FDA) recommends.
For example, if it’s considered safe to take only one pill per day of a certain drug, we may only cover that drug for one pill per day.
Quality Assurance Procedures
We have quality assurance policies in place to protect you. For details, check your plan's Evidence of Coverage.
Part B Versus Part D Drugs
Drugs that are identified as Part B versus Part D may be covered under Medicare Part B or D depending on the situation. More info may need to be submitted describing the use and setting of the drug to determine what it should be covered under. You or your doctor will be contacted in this situation.