Medicare Advantage Prescription Drug Resources

Formularies

Premier Performance Formulary

View the Premier Performance Formulary 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)

High Performance Formulary 

View the High Performance Formulary that applies to:

• MedMutual Advantage Signature (HMO)
• MedMutual Advantage Access (PPO)

EGWP Group Formularies for:

Medical Mutual offers Employer Group Waiver Plans (EGWP) coverage to the following groups:

• Kaiser Permanente
• Howmet Aerospace, Inc.
• Diocese of Cleveland
• Bon Secours Mercy
• MMO Retirees
• Oberlin College
• Case Western Reserve University

View EGWP formularies by visiting the 2024 MedMutual Advantage Group Plan Information page and entering the group number listed on the member's ID card.

Coverage Review Process

If your patient or a pharmacist requests your help in completing a coverage review, please call 800.753.2851 to initiate the review. Express Scripts will fax a form for you 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 are able to 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.
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 prior authorization information, visit the Group Plan Information page and enter the group number listed on the member’s ID card.

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 quantity limit information, visit the Group Plan Information page and enter the group number listed on the member’s ID card.

View the quantity limits list 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 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 step therapy information, visit the Group Plan Information page and enter the group number listed on the member’s ID card.

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)