We have a team of doctors and pharmacists who create tools to help us offer benefits to our members. Some of the tools are listed and described below:
- Prior Authorization: We require you to get approval from us for certain drugs. We call this prior authorization. You may need a drug that is not on the List of Drugs. To get this drug covered, you will need to get approval. If you don’t get approval, you may be asked to pay for the drug.
- Age Limits: Some drugs require approval if your age does not meet what is advised by the FDA or clinical recommendations.
- Quantity Limits: Some drugs limit the number of pills for a specific number of days.
- Step Therapy: Some drugs require you to try a less expensive drug before “stepping up” to drugs that cost more.
You can ask Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) to make an exception to our coverage rules.
Refer to the List of Drugs for the types of exceptions. The doctor should submit a note with the Coverage Determination form filled out for a formulary or utilization exception.
We must decide within 72 hours of getting the note and form from your doctor. You or your doctor can request an expedited (fast) exception if your health is in danger. If the request for a fast exception is allowed, we must tell you our decision within 24 hours of getting the note and form from your doctor.
* Please note – This form cannot be used for Medicare non-covered drugs. Fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, and prescription vitamins (except prenatal vitamins and fluoride preparations) are examples of Medicare non-covered drugs.
Call Superior STAR+PLUS MMP for the most recent list of covered drugs. For questions, please call the Member Services department at 1-866-896-1844. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.
Last Updated: 10/01/2016