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MEDICARE

Coverage limitations drug search

Find the criteria and fax forms for drugs requiring prior authorization, step therapy, quantity limits.

When you search for your drug, the criteria and corresponding fax form will be displayed, along with details on which plans require the review. Review the drug's information and follow the steps on your plan's form to submit a request.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. 
To find a drug, use the search above or select a letter from the list above.

Brand Drug Name: {{header}}

results found

  • Generic Drug Name:
  • Benefit: ,
  • Specialty:
  • Prior Review Required On: ,
  • Value Prior Authorization: ,
  • Quantity Limits Required On: ,
  • Quantity Limits:
  • Restricted Access/Step Therapy:
  • Restricted Access/Step Therapy: , ,
  • Formulary Exceptions:
  • Formulary Exceptions: ,
  • Nonformulary:
  • Nonformulary On: ,
  • Criteria: ,
  • Fax Form: ,
  • Note:


No results found for '{{header}}'