Prescription Utilization Management 2023
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: Martin's Point Generations Advantage requires you to get prior authorization for certain drugs. This means that you will need to get approval from Martin's Point Generations Advantage before you fill your prescriptions. If you don't get approval, Martin's Point Generations Advantage may not cover the drug.
Download the 2023 Prior Authorization Criteria for Focus DC Plan (PDF)
Download the 2023 Prior Authorization Criteria for Prime and Select Plan (PDF)
Download the 2023 Prior Authorization Criteria for Value Plus (PDF)
Quantity Limits: For certain drugs, Martin's Point Generations Advantage limits the amount of the drug that the plan will cover. For example, Martin's Point Generations Advantage covers 60 capsules per 30 day prescription for celecoxib 200mg.
Step Therapy: In some cases, Martin's Point Generations Advantage requires you to try safer or more effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "Step Therapy." You can find out if your drug has any additional requirements or limits by looking in the 2023 online formulary.
Download the Step Therapy Criteria for 2023 Focus DC Plan (PDF)
Download the Step Therapy Criteria for 2023 Prime and Select Plan (PDF)
Download the Step Therapy Criteria for 2023 Value Plus Plan (PDF)