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The main goal of Step Therapy is to promote safer, more cost-effective treatment by encouraging a “step” approach in evaluating prescription drug use. To receive the maximum plan benefit, you may first need to try a proven, cost-effective option before engaging in a newer treatment that may be higher-cost and higher-risk.
If your doctor determines that a first-line drug is not right for you, then your prescription drug benefit will cover second-line drugs, which are often less-preferred and more expensive.
Prior Authorization is required for certain high-cost, high-risk drugs, including those with the greatest potential for misuse. Before medications on the Prior Authorization list can be covered under your plan, your doctor will need to give approval.
If you have questions about Step Therapy or Prior Authorization, please call the Pharmacy Program number on the back of your member ID card.
Most pharmacy benefit plans include the Prior Authorization program. Prior authorization helps encourage the appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met.
Drugs requiring prior authorization are designated in the Formulary by "PA" (Prior Authorization) under the Restrictions information. These drugs require prior authorization before members can obtain them as a covered benefit. Drugs requiring prior authorization are subject to change. Please check your provider manual, contact Memorial Hermann Health Solutions or contact our pharmacy benefit manager for a current list of drugs requiring prior authorization and for their coverage criteria. If prior authorization is required, the physician (or his/her representative) must call OptumRx Customer Service at (877) 633-4461 or fax the request with supporting clinical information to Memorial Hermann Health Solutions pharmacy benefit manager at (866) 511-2202.
Download a Prior Authorization Request
Download our Prior Authorization Criteria Detail
Download our Specialty Drug Criteria Detail
Some drug products may be subject to quantity level limits based on the drug manufacturer's packaging size or adopted clinical guidelines. These drugs are designated in the Formulary by "QL" (Quantity Limits) under the Restrictions information. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity level limits are subject to change.
In some cases, Memorial Hermann Health Plan 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, Memorial Hermann Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.