Pharmacy Utilization Management

MDwise Medicare plans have requirements for some drugs that need to be followed before we will cover them. These requirements are: prior authorization, step therapy, and quantity limits.

Note: Formularies effective as of July 9, 2024

Prior Authorization

Certain drugs require approval before we will cover them. Your doctor should contact us to receive this approval before prescribing you a drug that requires prior authorization or we will not cover it.

Drugs that require prior authorization 2024 - HMO/HMO-POS (pdf)

Step Therapy

Sometimes, you will be required to first try another drug to treat your medical condition before we will cover the drug your physician initially prescribed. This is called step therapy.

Drugs that require step therapy 2024 - HMO/HMO-POS (pdf)

Quantity Limits

Some drugs will have limits on the amount of the drug we will cover over a certain period of time. This is called having a quantity limit. This requirement is used for quality, safety, and utilization reasons.

Drugs that have quantity limits 2024 - HMO/HMO-POS (pdf)

You can also see which drugs have these requirements by looking at our online formulary or “Drug List”

To request coverage for a drug that requires prior authorization or to request an exception to one of these requirements, you can submit a request for a coverage determination or download the coverage determination form and return to:

By Mail:

Attn: Prior Authorization
10181 Scripps Gateway Ct
San Diego CA 92131

By Fax:


CMS Material ID: H7746_MDwiseWebsite
Updated: 7/9/2024 11:56:02 AM