Pharmacy medical management policies

For Illinois and Missouri Medicare Advantage plan members

Our medical management includes:

• Prior Authorizations for medical injectables drugs. See Medicare Part B Prior Authorization List and our Medicare Advantage Prior Authorization form PDF (updated 10/1/23).
  • All Medicare Prior Authorization reviews will be performed following our policy: Medicare Prior Authorization Review without a NCD/LCD. (PDF)
• Preferred and non-preferred drug list for Medical Step B injectable drugs. See our 2024 Medical step B therapy list PDF (updated 11/1/2024) and exception to coverage form. PDF (updated 10/1/23)

Our medical policies

Services will be reviewed according to the Medicare Coverage Guidelines, established by the Centers for Medicare & Medicaid Services (CMS). According to the guidelines, all medical care, services, supplies and equipment must be medically necessary.

In scenarios where CMS does not provide guidance on the particular medical care, service, supplies and equipment, we will use MCG (formerly Milliman Care Guidelines) criteria or a medical policy of ours. See the our Prior Authorization Medical Service List to access the medical policies relevant to the services you are requesting. See our Medicare Advantage Prior Authorization form. 

Additional information

Additional Information about medical management can be found on our Medical Management page. Key resources include:

• Radiology policies (NIA/Magellan Health/Evolent)
• Behavioral health 
• Musculoskeletal program (NIA/Magellan Health/Evolent)