Medicare Advantage Prescription Drug Resources
This page contains information on Medicare formularies and coverage management criteria (e.g. prior authorization, step therapy).
Formularies
EGWP Group Formularies for:
- Kaiser
- Howmet Aerospace
- Diocese of Cleveland
- Fisher Titus
- Case Western Reserve University
Visit the 2023 MedMutual Advantage Plan Information & Resources page and enter the group number from the member ID card.
Premier Performance Formulary
Applies to Classic, Choice, Plus, Secure, Select, Preferred and Premium Plans
View the 2023 Premier Performance Formulary.
High Performance Formulary
Applies to Signature and Access Plans
Coverage Review Process
If your patient or a pharmacist requests your help in completing a coverage review, please call 1-800-935-6103 to initiate the review. Express Scripts will fax you a form to fill out and return. Please note that a timely response is important. If medication is needed before approval, your patient will have to pay the full cost of the medication out-of-pocket, which is reimbursable (less co-pay) if the prescription is approved.
Our pharmacy benefit manager, Express Scripts, now offers an online prior authorization portal for providers called ExpressPAth. Using ExpressPAth you can initiate new prior authorization requests, complete existing prior authorization requests or check the status of previously submitted prior authorization requests. To use this tool, access the ExpressPAth Prior Authorization Portal for providers.
Express Scripts will send you and your patient a letter that confirms or denies coverage approval (usually within 2 business days of receiving the necessary information).
If coverage is approved, your patient will pay the normal co-payment for the medication. If coverage is not approved, your patient will be responsible for the full cost of the medication. Your patient has the right to appeal the decision. Information on the appeal process will be included in the letter you receive.
Prior Authorization
We require prior authorization for certain drugs. Specific clinical criteria will need to be met for use of these drugs. Learn more about prior authorization guidelines for different prescription drugs using the resources below. For EGWP Plans, please refer to the group site.
View the prior authorization guidelines that apply to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the prior authorization guidelines that apply to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)
Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For a list of quantity limits, please refer to our complete listings below. For EGWP Plans, please refer to the group site.
View the quantity limits list (updated October 1, 2022) that applies to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the quantity limits list (updated October 1, 2022) that applies to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)
Step Therapy
In some cases, we require patients to first try one drug to treat a medical condition before we will cover another drug for that condition. Learn more about the criteria for step therapy below. For EGWP Plans, please refer to the group site.
View the step therapy criteria that apply to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the step therapy criteria that apply to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)