Prior Authorization, Step Therapy, & Quantity Limits

What are Utilization Management tools or requirements?

Within each formulary, which is a CMS approved list of medications covered by Alterwood Advantage, are additional utilization management (UM) requirements that must be met on certain formulary drugs for coverage. These are utilization management tools we use to ensure appropriate and medically necessary use of these drugs. These UM requirements are described below.

  • Coverage Decision (aka Prior Authorization or PA): You [or your physician] must get prior authorization for certain drugs.  This means that you will need to get approval from Alterwood Advantage before you fill your prescriptions.  If you don’t get approval, Alterwood Advantage may not cover the drug.   
  • Quantity Limits (QL): For certain drugs, Alterwood Advantage limits the amount of the drug that Alterwood Advantage will cover. For example, Alterwood Advantage provides 30 tablets per prescription for amlodipine-atorvastatin oral tablet 10-10 mg. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy (ST): Alterwood Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.  For example, if Drug A and Drug B both treat your medical condition, Alterwood Advantage Choice may not cover Drug B unless you try Drug A first.  If Drug A does not work for you, Alterwood Advantage Choice will then cover Drug B. 

All formularies offer you and your doctor a variety of choices to treat your condition. You may view or download a copy of the formularies and UM documents below.

What is a tier?

A tier is a drug category that defines your out-of-pocket expense (i.e., copay or coinsurance) for a prescription.

Drugs within our formularies are categorized into one or more tiers. The number of tiers for each formulary is listed below.

More details describing these tiers can be found within each formulary that you can view or download above.