FirstMedicare Direct  
 

 

Prior Authorizations and Step Therapy

What are Prior Authorization Requirements?
FirstMedicare Direct may require “prior authorization” for certain prescription drugs before they are covered.  Prior authorization is used to make sure a drug is being used correctly and only when medically necessary.  When a drug requires prior authorization, your prescriber must first contact us and document the reasons the particular drugs are medically necessary for you. Our prior authorization requirements for specific drugs can be found in the document below.

2020 Prior Authorization Requirements (HMO Formulary) Adobe PDF

2019 Prior Authorization Requirements (HMO Formulary) Adobe PDF

2019 Prior Authorization Requirements (preferredPlus HMO) Adobe PDF

2020 Prior Authorization Requirements (PPO Formulary) Adobe PDF

2019 Prior Authorization Requirements (PPO Formulary) Adobe PDF

What are Step Therapy Requirements?
FirstMedicare Direct may require “step therapy” for certain prescription drugs before they are covered.  In most cases, step therapy requires that you first try certain less expensive drugs that are also approved for your condition, before stepping to a more expensive drug. Your prescriber can contact the plan for a step therapy exception if you have already tried the less expensive alternative(s) with poor response or if your condition makes it medically necessary for you to use the more expensive step therapy. Our step therapy requirements for specific drugs can be found in the document below.

2020 Step Therapy Requirements (HMO Formulary) Adobe PDF

2019 Step Therapy Requirements (HMO Formulary) Adobe PDF

2019 Step Therapy Requirements (preferredPlus HMO) Adobe PDF

2020 Step Therapy Requirements (PPO Formulary) Adobe PDF

2019 Step Therapy Requirements (PPO Formulary) Adobe PDF


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FirstCarolinaCare Insurance Company’s FirstMedicare Direct plans are HMO and PPO plans with a Medicare contract. Enrollment in a FirstMedicare Direct plan depends on contract renewal.This is a required statement by CMS. FirstCarolinaCare has filed and been approved to offer an HMO and a PPO Medicare Advantage Prescription Drug plan for 2020.

 
Y0094_20042M_Accepted_10/01/2019

Page Last Updated:
Friday, October 2, 2020 11:13:14 AM