Prescription Drug Benefits

Prior Authorization Criteria

HealthSun requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.

2023 Prior Authorization Criteria – updated 04/06/2023

Step Therapy Criteria

In some cases, HealthSun 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, the 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.

2023 Step Therapy Criteria – updated 04/06/2023

2023 Step Therapy Criteria Part B Drugs only – effective 01/01/2023

Exceptions to the HealthSun Drug Formulary

You can ask HealthSun to make the following exceptions to our Prescription Drug coverage rules:

• Cover a drug that is not on our Formulary. If approved, it will be covered at a pre-determined cost-sharing level and will not be allowed to a lower cost-sharing level.
• Cover a Formulary drug at a lower cost-sharing level if it is not on the specialty tier. If approved, this would lower the cost of your drug.
• Waive coverage restrictions or limits on your drug. For example, for certain drugs, HealthSun limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HealthSun will only approve your request for an exception if the alternative drug is included on our Formulary.  The lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact our Member Services Department to ask us for an initial coverage decision for an exception on the Formulary, tiers or a utilization restriction. You should also submit a statement from your prescriber or physician supporting your request.  Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.  Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.