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Policies and Guidelines

Drug Management Policies

Drug Coverage Policies

Important note: Before using these policies, read Coverage Policy Usage Notice.

Prior Authorization Policies

Before using these policies, read Utilization Management Policy Usage Notice.

Important Note for Medical Benefit Drugs: It is required that prior authorization be obtained before services are rendered. Beginning with January 1, 2014, dates of service, if any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.

Access the Claim Appeal Request Form at »

Medica reserves the right to conduct a medical necessity review at the time the claim is received.

Medical Benefit Applies

Prior Authorization Changes for Medical Benefit Drugs

Effective with March 2, 2015 dates of service, Medica requires prior authorization for certain medical benefit drugs. This program is administered by Magellan Rx. 

View related drug policies » (available at Magellan Rx) 

Learn more using the following resources: 

Medical Pharmacy Claims – Edit Policies 

For certain medications billed under the member’s medical benefit, Medica applies pre-payment claims edits to diagnosis criteria and criteria for maximum units. As outlined in Medical Pharmacy Claims-Edit Policies for these medications, these edits verify that claims are paid in accordance with each policy’s stated clinical criteria as well as the maximum units previously authorized. 

This program is administered by Magellan Rx.

Note: Prior authorization criteria will not apply for all of these policies, necessarily, and this will be noted in each respective policy. 

View related drug policies »

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