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Drug Coverage Limits

Some prescription drugs are covered by Medicare Part B and others by Medicare Part D.

Usually, you can't take Part B drugs on your own. You might go to your doctor's office to get them through a needle or an IV. The amount you pay is based on Medicare Part B rules.

Part D drugs are the ones listed in our covered drug list. The amount you pay is based on their tier. Your plan covers these drugs as long as:

  • The drug is medically necessary, meaning you need it to treat a condition you have
  • You and your provider follow all the rules around prescription drugs

Some Part B and Part D drugs may have the following limits on their coverage.

Prior authorization (PA)

This means your provider has to check with us first to make sure we'll cover the drug. To see which drugs require prior authorization, check our:

Quantity limits (QL)

With some drugs, you’re covered for only a limited amount of medicine — or for a set length of time. These are called quantity limits. For example, you might only be covered for 30 pills in one month.

Step therapy (ST)

Before you can get certain drugs, you first need to try one that costs less and typically works for your condition. If the lower cost drug doesn’t help, then you can step up to the more expensive one. To see which drugs require step therapy, check our:

Opioid rules

To help address the opioid crisis, the Centers of Medicare and Medicaid Services (CMS) created special rules for opioid prescriptions. Learn how these rules could affect you.

If you have any questions — or you can't find your medications in our list — give us a call at 1-800-338-6833, TTY 711.