Pharmacy medical management policies

For Illinois and Missouri Medicare Advantage plan members

Our medical management includes:

Our medical policies

Services will be reviewed according to the Medicare Coverage Guidelines, established by the Centers for Medicare & Medicaid Services (CMS). According to the guidelines, all medical care, services, supplies and equipment must be medically necessary.

In scenarios where CMS does not provide guidance on the particular medical care, service, supplies and equipment, we will use MCG (formerly Milliman Care Guidelines) criteria or a medical policy of ours. See the our Prior Authorization Medical Service List to access the medical policies relevant to the services you are requesting. See our Medicare Advantage Prior Authorization form

Additional information

Additional Information about medical management can be found on our Medical Management page. Key resources include:

View our Medicare disclaimer.