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Medicare ᏗᎾᏓᏁᏢᏍᎩ

ᎢᎩᏓ

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Here you will find pharmacy-related information, including the Medicare formulary, as well as links to request or appeal drug coverage.

AcariaHealth Specialty Pharmacy
Available at no additional cost to patients undergoing treatment for long-term, life-threatening or rare conditions.

Express Scripts® Pharmacy Mail Service
Tell your patients about this convenient way to have maintenance medications delivered to their doorstep. Members can sign up at express-scripts.com/rx.

Coverage Determination 
Request coverage or exception for a prescription drug.

Medication Appeals 
Appeal a coverage determination decision.

Formulary
Use the Find My Plan tool to find the most up-to-date complete formulary.

ᏅᏬᏘ ᎤᏂᏍᏆᏂᎪᏙᏗ ᏗᎧᎵᎢᏍᏗ

We strive to cover the most common drugs across all conditions. Below are some common drugs not covered by the plan, along with alternative drugs that are covered. If your patient is currently on a drug that is not covered, please see if the formulary alternatives listed below would work for your patient.

This policy provides a list of drugs that require step therapy effective January 1, 2024. Step therapy is when we require the trial of a preferred therapeutic alternative prior to coverage of a non-preferred drug for a specific indication.

MCPB.ST.00: This policy provides a list of drugs that require step therapy. Updated July 31, 2024

MCPB.ST.00: This policy provides a list of drugs that require step therapy. Effective January 1, 2025

Drug Prior Authorization Requests Supplied by the Physician/Facility

Fill out and submit this form to request prior authorization (PA) for your Medicare prescriptions.

Fill out and submit this form to request an appeal for Medicare medications.

Reference Guides


Contains key phone numbers and information on claims, appeals and more.

Pharmacy Clinical Policies

Crizanlizumab-tmca (Adakveo®) is a selectin blocker.

Cerliponase alfa (Brineura®) is a hydrolytic lysosomal N-terminal tripeptidyl peptidase.

The following are factor VIII products requiring prior authorization: human – Hemofil M®, Koate-DVI®; recombinant – Advate®, Adynovate®, Afstyla®, Eloctate®, Esperoct®, Helixate FS®, Jivi®, Kogenate FS®, Kogenate FS with Vial Adapter®, Kogenate FS with Bio-Set®, Kovaltry®, NovoEight®, Nuwiq®, Obizur®, Recombinate®, ReFacto®, Xyntha®, and Xyntha® Solofuse™.

Factor VIIa, recombinant (NovoSeven® RT) and coagulation factor VIIa (recombinant)-jncw (SevenFact®) are coagulation factors.

Patisiran (Onpattro™) is a double-stranded small interfering ribonucleic acid, formulated as a lipid complex for delivery to hepatocytes.

Mogamulizumab-kpkc (Poteligeo®) is a CC chemokine receptor type 4 (CCR4)-directed monoclonal antibody.

Eculizumab (Soliris®) is a complement inhibitor.

Trientine (Syprine®) is a chelating agent.

Ravulizuamb-cwvz (Ultomiris®) is a complement inhibitor.

Golodirsen (Vyondys 53TM) is an antisense oligonucleotide.

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Last Updated On: 11/1/2024
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